Classification of headache

1)
2) Headache associated with head trauma
3) Headache associated with vascular disorder
4) Headache associated with non-vascular intracranial disorder
5) Headache associated with sub & their withdrawal
6) Headache associated with non-cephalic infection
7) Headache associated with metabolic abnormality
8) Headache or facial pain associated with disorders of cranium, neck, eye, ear, nasal cavity, teeth,
mouth & other facial or cranial structures
9) Cranial neuralgia, nerve trunk pain
10) Other types of headache or facial pain
11) Headache not classified
Investigations
1)Neuroimaging indication

Headache features:

 1st or worst headache

 Subacute headache with frequency or severity

 Progressive, persistent headache

 Chronic daily headache

 Headache always on same side

 Headache not responding to ttt

Associated signs & symptoms:

 Seizures

 Fever, neck stiffness

 Nausea, vomiting

 Focal neurologic S or S

 Papilldema

 Cognitive impairment or personality changes

2)EEG

To evaluate patient with headache suggesting a seizure disorder

3) Lab
ESR, CBC, LFT, TSH, Ca

4)Lumbar puncture

Headaches diagnosed by LP:

 Infections (meningitis or encephalitis)

 Neoplastic disease (meningeal carcinomatosis or lymphomatosis)

 SAH

 High & low CSF pressure

 Stratified care: migraine is stratified into 5 degrees



Mild
NSAID & metoclopramide

Moderate
5HT agonist
Rectal antiemetic may be added

Sever
Oral/nasal tryptan
Rectal DHE (dihydroergotamine)

Very sever
Chloropromazine
Antihistaminic
Rectal NSAID
Opiod & rectal antiemetic
 Refractory
ACTH
K sparing diuretics
Drugs in 4th degree

Headache
Def

Pain or discomfort in area from eye brow infront to subocciput behind

Epid

Irritation ,compression& traction of pain sensitive structures intracranial or extracranial

Classification
1) Primary headache : HA is the maine dse eout underlying cause
a) Migraine
b) Tension-type headache
c) Cluster headache
2) 2ry headache: HA is a symptom for underlying cause : HTN_BRAIN TUMOR

Migraine
Def Episodic chronic 1ry H/A disorder lasting 3h-3d
Ass é N, V, phono, photo-phobia
Epid Common cause in young age (15-35ys)
Affect 10-15% population, ♀:♂ = 3:1
Character C The headache has at least two of the following features:
M Unilateral localization
M Pulsating or throbbing character
M Moderate or severe intensity(makes everyday activities difficult or impossible)
 M Exacerbation by habitual physical activity as exertion, walking, or climbing stairs.
D At least one of the following symptoms is present during the headache:
M Nausea and/or vomiting.
M Photophobia or phonophobia.
types Migraine e aura Migraine eout Complicated
(classic) Aura migraine
(common)
Aura precede HA : mostly Visual: flashes zigzag lights, A e transient
scotoma hemiplegia or
Less common sensory or speech disorder ophthalmoplegia
Risk for ischemic stroke
pathophysiol Vascular VC (aura) then VD (HA)
ogy

Neurovascular Migraine Triggers >>++ (CSD) Cortical spreading depression (begin in occipital)>>>+++
TG nerve >>>release neuropeptides (pain activator)
Serotonergic Serotonine release in blood ( bl level) >>> VC then release in urine ( bl level) >>>VD

Integrated Include all of above

theory
triggers Diet: alcohol, tyramine, smoking straining
Stress & exercise Lack of sleep Noise &bright lights
DD Focal seizures, TIA (rapid onset while migraine slow)
Other 1ry H/A: TT, Cluster
2ry H/A: Tr, infection, non-vasc, substance, blood, psychiatric, ENT
Migraine H Tension H Cluster H

Male: female 1:3 2:3 9:1

Lateralization 60% unilateral Bilateral, diffuse 100% unilateral
Location Frontal, periorbital, hemicranial Diffuse Periorbital
Frequency 1-4/m 1-30/m 1-3/d for 3-12m
Duration 4-72hr Variable 15m-3hr
Character Pulsating Dull Sharp, boring
Aura  - -
Autonomic  - 
 by movement  - -

Acute treatment Prophylaxis

Start at bottom of the pyramid &  gradually
1. 1st line: simple analgesic
2. 2nd line: combination analgesic
3. 3rd line: specific antimigrane therapy
5HT1 agonists (selective & non-selective)
NSAID
Dopamine antagonist & prokinetics
Opiods: if 5HT1 agonist ineffective or CI
Indication:
a)≥2 attacks /m produce disability lasting ≥3 days
b)CI or ineffectiveness of symptomatic ttt
c)Attacks of complicated types e.g. hemiplegic migraine
Recommendation:
a) Start low & go slow
b) For 6m up to years of continuous therapy
Episodic prophylaxis:
Non-medical treatment: when trigger factors is established e.g.: menses, sexual

TTT: Acute attack Prophylaxis

5-HT1 agonist 5-HT2
Non-selective Selective antagonist
Prepar Ergotamine: Sumatriptan: Methysergide: 2mg 1x3
2tab at onset, 2tab, repeat/2h for 3 times Cypro-heptadine less effective
repeat /30min Nara-tryptan Pizo-tifen used in children
up to 6 tab/d Zolmi-tryptan ( In severe refractory migraine )
DHE
Forms Migranil Imigrane (Sumatriptan)
Tab: (1mg ergotamine + Tab: (50,100 mg),repeat/2hr
50 caffeine + 200mg Amp: (6mg) SC at onset
analgesic) Intranasal
Rectal: supp Zolmitryptan (No-migran)
VC of ECA & its branches VC, ↓release SP Prevent VC
N,V, stroke, PN, damage Parasthesia Wt gain
Action
post col Chest heaviness Retroperitoneal, pleuropericardial,
SE
Transformed H/A Diff breathing subendocardial fibrosis
Coronary HD → →
é other VC → →
CI
Preg, Raynaud's Non-ttt TIA
NSAIDs NSAIDs
ASA, acetaminophen → 650mg/4h
Naproxen 750mg/d & Indomethacin 50mg 1x3 Naproxen & Tolfenamic acid
Prepar
Central (-serotonin), Periph (-PG synthesis) →
Action 1st choice in : Episodic prophylaxis only d2 SE
Indicat Migraine é IHD, HTN, vascular claudication
CI Allergy, preg, GIT bleeding

D antagonist, Opioids GABA-ergic BB CCB Anti-depressant

prokinetic drugs drugs
Prepar Chlorpromazine Valp Propranolol Flunnarizine Amitryptal
Prochlorperazine Gabapentin 10-40mg/d Verapamil SSRI
Metoclopramide Topiramate Atenolol Nimodepine
50-200mg/d
Action ↓N, V 5-HT2 antag Memb ↓N.ad, 5-HT
↑motility BB stabilizer reuptake
↑drug absorptn
Indicat Chloropromazin é IHD é BA, HF, AV é stress, HTN é HTN, BA, é insomnia
(Neurazine): block Raynaud's Transformed
SE 50-100mg IM Sedation Impotence Extra-∆
No-migrane tab Cognitive slow ↓BP Arrhyth
(1mg ergot + Addiction ↑Wt
CI 50mg caffeine + BA Parkinson,
 250mg CHF AV block
paracetamol + AV block Depression
10mg domperidon

Non-medical ttt migraine seizures: Others:

Induction sleep Clonidine: + bulbospinal –ry pathway
Ice bag application Riboflavin: for altered mitoch function
Dark room Mg replacement: ↓Mg found in migraine
Meditation BTX injection

Non-migrainous Vascular H/A

1) Cranial arteritis
Def Vascular H/A ass é tender indurated temporal a
May present medical emergency d2 potential loss vision
Epid >50Y
Path Granulomatous vasculitis é fragmentation int elastic lamina of extra-cranial arteries
Inflam cells, multinucleated giant cells & Occluded lumen
CP Feature: severe, throbbing, ↑é contact pillow, worse at night
Ass: tender indurated temp a, tender scalp, systemic manif (anorexia, ↓wt, fever, night sweat)
Comp Blindness (15-50%): occlusion Ophthalmic/CRA
TIA, ischemic stroke: Vertebral/carotid art
Facial pain, jaw claudication: Ext carotid art
Inv Mild anemia, ↑platelet, ↑liver enz, ↑ESR, ↑CRP
MRI, Angiography: alternating stenosis, dilatation (beading app)
Biopsy from temp a (2cm at least): patchy inflam (mainstay D)
TTT Prednisolone: 60-80mg/d for 2-4wks → gradual édrawal guided by ESR, sympt
ttt continued for 1Y at least (average 2-4Y)
2) Cerebral thrombosis, arterial dissection:
Cerebral infarction VST Arterial dissection
Sudden severe throbbing pain Thunderclap H/A like SAH Sudden, severe unilat, thunderclap H/A
Carotid → frontal Carotid → orbital/facial
Vertebral → occipital Vertebral → neck pain
3) Intra-cranial Hge:
ICH SAH SDH
Acute onset Sudden onset Insidious onset, intermittent, fluctuat
Ass focal signs, loss consc Ass neck pain, M irritation Ass focal signs, seizures
Cerebellar → occipital Photo, phono-phobia
Aneurysm → compress 5
4) Others: change caliber/permeability cranial vessels
Anemia, Fever, High altitude HTN, pheochromocytoma Drugs: CCB, OCP, steroid édrawal
↓Glu, ↑thyroid Pre-eclamptic toxemia ↑tea, coffe & caffeine édrawal
Pulm dis, OSAS, ↑CO2 Ice cream H/A
 Trigeminal Neuralgia (Tic Douloureux)
Def Paroxysmal brief attacks severe lancinating pain in distribution ≥1 division 5 th CN
AE 1ry
2ry: MS, CPA Tm, schwannoma, Mg infiltrate skull base, Dandy vasc loop nerve compression
CP Age: >40Y & Sex: ♀>♂
Pain: sudden, severe, brief, paroxysmal lancinating
Site: V2,3 (60% Rt, 39% Lt, 1% bilat)
Time: last <1min, variable frequency, rarely awaken ptn from sleep
PPT by: + skin, mm, teeth (chewing, eating, cold)
Ass é: lacrimation, flushing face, salivation, spasm facial ms (painful tic = tic douloureux)
TTT Medical Surgical (also é cluster)
1ry Analgesic Alcohol block PN or ganglia
VitB Section S root
AED (CMZ, gabapentin, phenytoin, valp, Microvasc decompression
topiramate, pregabalin, clonazepam) Radiofrequency thermocoagulation S root
Steriotactic radiosurgery é gamma knife
DD: 2ry TN (Tm) Pain continuous (not paroxysm)
Facial S loss (early), weak mastication, loss corneal Rx (late)
Pain Other CN affection & CT/MRI
Para-TN lesion middle cranial fossa (nasophx carcinoma, granulomatous infection)
(Raeder's synd) Pain, S loss V1, max around eye, ophthalmoparesis, Horner
Referred pain Nasal sinusitis, dental carries, eye dis (glaucoma)
Post-herpetic neuralg HZV → V1 → painful rash, involve cornea
Central pain continuous severe burning pain
(thalamic synd) affect ipsilat limb, trunk
Psychogenic middle aged ♀, depression (respond antidepressant > analgesic)
(Atypical facial pain) pain dull, continuous, poorly localized, usually start in upper jaw, unilat/bilat
Migrainous neuralgia Paroxysmal pain distrib 5th , but long duration, no PPF
TMJ dysfunction (malalignment, arthritis) Aching pain around ear, spread to face, temporalis,
(Costen's synd) provoked by chewing, tender on touch
Carotidynia Intermittent facial pain, tenderness of carotid artery, PPT by alcohol
Carotid dissection Acute retro-orbital pain, Horner
Gradenigo synd 6, 7, V1,2 (Apical petrositis d2 supp OM)
Tolosa Hunt synd Granulomatous inflam cav sinus (parasitic, TB, SLE)
Recurrent, MRI: soft tissue in cav, TTT: steroid
3,4,6, V12 é intact pupillary function
Other Glosso-Phx Tonsils, post phx, back tongue, Middle ear
Neur- Occipital Along distribution greater, lesser occipital n
algia Naso-ciliary Orbit (↑by touch med canthus) + rhinorrhea
Sphenopalatine gang Orbit, base nose, maxilla + rhinorrhea
Greater superf petrosal Medial canthus, base nose, maxilla (↑by sneezing)
Geniculate gang Ear (Tm, AVM)
Nervous intermedius Ear (? VZV)
 CH
Def 5 severe unilat H/A attacks last ¼-3h
Acc by ipsilat autonomic symp, restless, agitation
Types Episodic: daily attacks for 6-12wk & Remission
(attack free period for m-y)
Chronic: attack for >1Y éout remission
CP ♂, 3rd decade & smoker, alcohol
Coarse facial skin, deep nasolabial fold, hazel eye col
H/A Strictly unilat, around eye
Severe, boring (suicidal H/A)
Last ¼-3h, frequency 2-3/d
May awaken patient from sleep
Autonomic: conj injection, nasal block, facial
flushing, sweating, swelling, Horner
PPt by VD drugs (histamine or nitroglycerine)
Relieved by: Oxygen, Physical exercise, Press on
eye or temple with hand, ice back
A At least 5 episodes fulfilling criteria B through D,
B Severe unilateral orbital, supraorbital and/or
temporal headache attacks, which last untreated for
15–180 min.
C The headache is accompanied by at least one of
the following symptoms ipsilateral to pain:
1. Conjunctival injection or lacrimation
2. Eyelid edema
3. Miosis and/or ptosis
4. Nasal congestion and/or rhinorrhea
5. Forehead and facial sweating
6. A sense of restlessness and agitation
D The attacks frequency from 1 every other dto 8/d
E History or physical and neurological examination
do not suggest any other disorder and/or they are
ruled out by appropriate investigations.
Inv MRI: if atypical or chronic
Eye pressure: exclude glaucoma
TTT Acute:
O2: flow rate of 7L/min for 20 min in a sitting
position. Mechanism may be CBF, Cerebral VC
Ergotamine,DHE: rectal
Suma, Zolmitriptan: 6mg sc
Prevent:
Verapamile: (The cornerstone)
Dose: 80mg 4times/d.
Side effects: bradycardia, edema, GI (Regular ECG monitoring is required)
Lithium: (rapid improvement, better tolerability than verapamil).
TTH (Ms cont H/A)
Recurrent attack like episodes last h-d
é freedom from sympt in( ) attack
Episodic: 1-14d/m
Chronic: >15d/m
Any age & Anxiety, depression
Tender Cx, paraspinal ms, scalp
Diffuse, Bilat, O-nuchal /bi-T /bi-F
Dull, perhaps throbbing character
Mild/Mod, Tight band/pressure
Last h-d
Not ass N, V, photo, phono-phobia
 if patient bends over or strains.
Time it appears at unpredictable times over the
course of the day, but most often in the morning on
awakening or just after arising
A ≥10 episodes fulfilling criteria B–D, occurring
fewer than 6 months/year.
B Headache episodes last 30 min to 7 days.
C At least two of the following pain characteristics
are present:
1. Bilateral
2. Pressing, not pulsatile,
3. Mild to mod , not impairing daily activities,
4. Not by physical activity as exertion, walking,
or climbing stairs.
D Both of the following characteristics:
1. No nausea or vomiting
2. No or very rare photophobia or phonophobia.
E At least one of the following is true:
The history and physical findings are not consistent
with another known type of headache
Other types of headache can be excluded with
ancillary tests
ESR: exclude temp arteritis
CT, MRI: ptn >40Y
Cx X-ray: detect 2ry TTH
Acute: NSAID, acetaminophen, ms relax
Prevent: amitryptaline
 Dose: 600–900 mg daily.
 Regular monitoring of: Pl conc (0·6 -1·2 mmol /L), liver, renal, thyroid function and electrolytes.
Side effects: are hyperthyroidism, tremor, and renal dysfunction.
Steroid: 40mg/d in a reducing dose over 3 weeks (70–80% of patients respond to steroids).
Others: Propranolol, Valproic acid
Indomethacin Responsive H/A CDH
Def H/A disorder ch by prompt, absolute, permanent H/A ≥4h/d &
response to indomethacin ≥15d/m & for >3m
TTT: indocid 25mg 1x3, ↑gradual, till 4x3 AE: central sensitization, ↓5-HT, ↓pain modulatn
If CI → celecoxib, NSAID, ergot, steroid Spontan central pain generation
Types Paroxysmal hemicranias: Chronic TTH
2nd, 3rd decade & ♀>♂ New persistent daily H/A
M Unilat, sever, ocular or periorbital & frontal pain (no P/H migraine, TTH, Tr, stress)
M Associated with autonomic disturbances
M Very frequent attacks 2-40/d
M Shorter than cluster headache 2min-2h
M The key feature is response to indomethacin
(150mg/d)
Hemicrania continua: Ch paroxysmal hemicranias
M Unilat (entire hemicranium/focal area Hemicrania continua
M Continuous, moderate, stabbing
M ± autonomic feature
SUNCT: Transformed migraine:
M Short-lasting unilateral neuralgioform headache Ch migraine: long lasting migraine attacks
attack with conjunctival injection & tearing Migraine é interparoxysmal H/A
M Attacks last from 30sec to 2min
1ry stabbing H/A: Analgesic rebound H/A:
Brief sharp pain, in any site head Tolerance to analgesics, édrawal sympt on stop

Cephalic pain = Facial pain + H/A

Trigeminal autonomic cephalgia = Cluster, Paroxysmal hemicranias, SUNCT
2 (optic canal)
3,4,6, V1 (SOF) V2 (rotundum) V3 (ovale) … Cav sinus (tolosa) 3,4,6 V12
7 (IAM, stylomastoid F) 8 (IAM) … CPA 5,7,8 & Gradenigo 6,7, V1
9,10,11 (jugular F) 12 (hypoglossal canal)