APPROACH TO PATIENTS WITH HEADACHE 1

HEADACHE INTRACRANIAL PAIN-SENSITIVE EXTRACRANIAL PAIN-SENSITIVE

- A common complain STRUCTURES STRUCTURES
o You cannot write headache as diagnosis – a symptom only - Venous sinuses - Scalp vessels and muscles
o Identify etiology – primary headache - Cortical veins - Orbital contents
 Migraine headache for example - Basal arteries - External middle ear
o If it is secondary write – “Headache secondary to meningitis” - Dura mater - Teeth and gums
- With > 300 causes - Mucous membranes of
- A symptom and not a disease nasal and paranasal spaces

CLINICAL NEUROANATOMY OF HEADACHE CLASSIFICATION OF HEADACHE

HEADACHE PRIMARY HEADACHES
- Not all headaches are caused by problems within the brain - Migraine
- Is the headache neurologic of secondary to something else outside - Tension-type
the brain? - Cluster headache & chronic paroxysmal hemicranias
- Head pain located above the orbital-meatal line (the line that IDIOPATHIC:
connects the outer canthus of the eye to the center of the external - Misc. headaches not associated with structural lesions
auditory canal) SECONDARY
o Craniofacial pain – headache + facial pain (below the line) - Headache associated with trauma
- With vascular disorders
KEY STRUCTURES INVOLVED IN PRIMARY HEADACHE - With nonvascular I.C. disorder
- Large intracranial vessels, dura matter, peripheral terminals of CN - Substance reslated
5 - With noncephalic infection
o CN5 – motor and sensory nerve - With metabolic disorder
 Sensory part can give us headache - With facial/cranial disorder
- Caudal portion of trigeminal nucleus which extends into the dorsal - Cranial neuralgias, nerve trunk pain, deafferentation pain
horns of C1 and C2 nerve roots - Unclassified
- Rostral pain-processing regions (e.g. VPM thalamus & cortex)
o Processes if it is pain or not PRIMARY VS SECONDARY HEADACHE
- Pain-modulatory systems in the brain (e.g. hypothalamus and COMMON CAUSES OF HEADACHE
brainstem) Primary Headache Secondary Headache
o Brainstem – where headache-causing neurotransmitters Mirgraine (16%) Systemic infection (63%)
come from Tension-type (69%) Head injury (4%)
Idiopathic stabbing (2%) Vascular disorders (1%)
INNERVATION OF THE HEAD Exertional (1%) Subarachnoid haemorrhage
- First branch of the trigeminal nerve (anterior and middle cranial (<1%)
fossa structures) Cluster (0.1%) Brain tumor (0.1%)
- Upper cervical roots C1 to C3 (posterior fossa & neck structures)
- A recurrent branch of the ophthalmic branch of CN5 innervates HISTORY
the tentorium
- If you had performed CT scan without analysing, if it comes out
- Cervical roots innervate the inferior surface
negative what do you tell your patient?
- The medullary nucleus of CNS juxtaposes upper cervical root entry
- If you do very good History and PE, even without CT scan you can
zone
tell what is ailing the patient
- Headache caused by lesions in the posterior fossa, upper cervical
o “To allay your worries, I will do a CT scan but I’m thinking it is
cord, or neck can be referred to the frontal head structures & vice
negative”
versa
o You can choose not to do CT scan if you are confident that the
headache is not serious
TRIGEMINOVASCULAR SYSTEM
- Innervation of the large IC vessels & dura by CNS
IMPORTANT DATA
- The medullary nucleus of CN5 juxtaposes the upper cervical root
- The first attack or previous attacks
entry zone  headache caused by lesions in the posterior fossa, - Whether onset is acute or gradual (days or weeks)
upper cervical cord, or neck can be referred to the frontal head - Whether attacks have recurred for many years (chronic)
structures & vice versa - Site of headache
- Accompanying symptoms
WHY IS THERE A HEADACHE WITH CERVICAL NERVE? - Precipitating factors/Relieving factors
- Back of the head dermatome:
o C1 – upper third SYMPTOM ANALYSIS OF HEADACHE PATIENT
o C2 – middle third - Patient factors
o C3 – lower third o Is my patient a worrier? Is my patient stressed out?
- Amy impingement on nerve root it can cause headache o Comorbidities?
o In addition to nape and shoulder pain o Substance abuser? Alcoholic?
- Headache description
o Associated symptoms
o Aggravating/alleviating factor
- Localization of pain
APPROACH TO PATIENTS WITH HEADACHE 2
- Aggravating factors - Frequent or daily; worse towards the end of the day
- Relieving factors
- Temporal sequence & frequency TREATMENT
- Other factors - REASSURANCE – number one!!
Other Aspects of the Headache History - Attempt to reduce psychological stress/relaxation
- Past History o Bed rest
- Social history o Massage
- Family history o Formal biofeedback training
- General functional inquiry - Benzodiazepines (e.g. diazepam, short-course) – if patient has
- Neurologic functional inquiry – very important difficulty relaxing
- Anti-depressants – if patient is depressed
EXAMINATION - NSAIDs – the pain reliever is just as good as its half-life
Complete General Examination o Acetaminophen 650mg PO Q4-6h
- If findings are normal, focus on things at the head area o Aspirin 650mg PO Q4-6h
o Check sinuses, ears, eyes o Diclofenac 50-100 mg Q4-6h
o Ocular o Ibuprofen 400mg PO Q3-4h
o Teeth and scalp o Naproxen sodium 220-550mg BID
o Percussion over frontal and maxillary sinuses - Combination Analgesics
- Complete neurologic examination – especially if patient is normal- o Acetaminophen plus butalbital (phrenilin generic and forte)
appearing o Acetaminophen plus butalbital plus caffeine (Esgicplus)
Formulate a diagnosis from the history, PE and neurologic exam o Aspirin plus butalbital plus caffeine (fiorinal)
o Aspirin plus butalbital (Axotal)
LOCALIZATION - If doing tests will reassure the patient and if the patient requests
- Is the headache neurologic or not? it, then you can do it
- Where is the problem and what is the lesion? - Prophylactic medications – attempt to decrease number of attacks
o Amitriptyline 10-50mg at HS
o Doxepin 10-75mg at HS
o Nortriptyline 25-75 at HS

MIGRAINE
- 70% of the time – patient has family history of migraine
- Unilateral throbbing headache
- Childhood or early adult life
- Typically at one side of the head
- 5-10% of population
- Female to male ratio 2:1
o 15% of women
o 6% of men

FORMS
- Migraine with aura – classic migraine
Cluster o Aura – premonitory symptoms  before start of headache
- Usually one eye patient can feel sensations that is difficult to explain
- There is tearing of the eyes from irritation - Migraine without aura – common migraine
Tension
- Contraction of the muscles of the head MECHANISMS
- Pain on the head and neck - Dysfunction of monoaminergic sensory control systems in the
Migraines brainstem & hypothalamus
- Usually unilateral but not all - Neurotransmitters implicated
o 5-HT/serotonin – very notorious for causing migraine
TENSION TYPE HEADACHE o Noradrenaline
- Most common form of headache o Dopamine – DR gene antagonist (new update on treatment)
o 70% of males o Control the diameter of intra and extracranial blood vessels
o 90% of females - DRD2 gene (G-protein coupled receptor for dopamine)
 Probably due to hormones or personality – worrier, has - No drug can cure migraine
attention to detail o Drugs only relieve the pain or decrease attacks
Mechanism
- Muscular due to persistent contraction
- Maximally felt at the end of the day
o Start of the day – muscles are relaxed
- Band-like sensation constricting the head and neck
S/S
- Diffuse, dull, aching, band-like, worse on touching the scalp and
aggravated by noise, associated with tension
- Hours to days
APPROACH TO PATIENTS WITH HEADACHE 3
- Methylprednisolone IM or IV for status migranosus – unrelenting
attack of migraine that lasts for days
o Usual attack of migraine is 1-2 days
o Some attacks persist for several days (status migranosus)
Mild migraine NSAIDs, combination analgesics,
Oral 5-hydroxytryptamine
agonist
Moderate migraine Oral, nasal, or SC 5-HT agonists,
oral dopamine antagonists
Severe migraine SC, IM, or IV 5-HT agonists;
IM or IV dopamine antagonists;
Prophylactic meds (flunarizine,
some anticonvulsants etc)
MIDAS (migraine disability
assessment score)

NONPHARMACOLOGICAL APPROACH
- In the brain we have blood vessels - Identify and avoid trigger factors
o Pressure of intracranial and extracranial vessels are different - Manage environmental shifts
 wide pressure difference disparity  lack/depression of o Time zone shifts
neural supply to certain parts of the brain  HEADACHE! o High altitude
- at the start of the headache there is only one part of the brain that o Barometric pressure changes
is affected  after sometime there is widening of the area of o Weather changes
depression - Assess menstrual cycle relationship
Report:
CORTICAL SPREADING DEPRESSION - If migraine coexists with another painful condition it can increase
- brief wave of excitation  prolonged period of neuronal incidence of suicide (e.g. fibromyalgia)
depression (with disturbances in nerve cell metabolism & regional
reductions in BF) CLUSTER HEADACHE
- migraine aura result from CSD that suppresses neuronal activity as - More often in men than in women
it passes forward over CC - Middle age
- migraine without aura usually with no CBF abnormalities - Severe unilateral pain around one eye associated with conjunctival
infection, lacrimation, rhinorrhea, and transient horner’s
SPECIFIC TYPES syndrome
- basilar – dizziness, patient unable to move both arms and legs o Histamine cephalalgia – associated with histamine
o first impression – stroke  but patient has persistent - Clusters of attacks separated by weeks or months
symptoms o 10 minutes – 2 hours
o If basilar migraine – after few hours immobility goes away o Once to many times per day, wakening sleep at night
- Hemiplegic – differential: stroke especially the first time - Histamine cephalgia
o Transient weakness on one side of the body
- ophthalmoplegic – transient weakness of eye muscles TREATMENT
- migraine coma – differential: hemorrhagic stroke - Antihistamines – it can also sedate the patient
o Difference: patient awakens in the first hours of migraine - Ergotamine/sumatriptan
coma - Prednisolone 30mg OD in refractory cases
- For prevention
PRECIPITATING FACTORS o Methylsergide
- Dietary: alcohol, chocolate (NOTORIOUS!), peanuts, cheese o Calcium channel blockers
- Hormonal (Estrogen) o Lithium carbonate
- Stress, fatigue, exercise, sleep deprivation, minor head trauma,
starvation OTHER CAUSES: Sinusitis, Posttraumatic headache
MANAGEMENT APPROACH TO PATIENTS W/ HEADACHE
- Avoid precipitating factors LABORATORY TESTS
- Prophylaxis for frequent and severe attacks - CBC – infection
o Pizotifen (5HT receptor blockers) - ESR determination – inflammatory, infection
o Propranolol (Beta blocker) - Cranial CT scan or MRI – neurologic lesion
o Methylsergide (5HT receptor blocker) - Lumbar puncture and CSF exam - document presence of bleeding
o Calcium antagonist in subarachnoid space, infection, inflammation
o Antidepressants - Cerebral angiography – aneurysm
o Anticonvulsants In preceding causes of headache, laboratory tests may not be done
unless physician would like to rule out a more serious disorder
TREATMENT WITH ACUTE ATTACKS - Try to rule out first the more serious possibilities!
- Analgesics with metoclopramide – for vomiting
- Sumatriptan
- Ergotamine
APPROACH TO PATIENTS WITH HEADACHE 4
HISTORY NEW ONSET HEADACHES IN PATIENTS OLDER THAN AGE 50
ONSET Primary Headache Disorders
Sudden - Migraine
- Previous trauma – CT scan to rule out bleeding or contusion in the - Tension type
brain - Cluster
- No trauma - Hypnic
o Nuchal rigidity?  subarachnoid haemorrhage (CT Secondary
scan/Lumbar Puncture) - Mass lesions
 From ruptured aneurysm - Temporal arteritis
 Or viral encephalitis - Medication-induced & rebound
o Supple? - Trigeminal neuralgia
 Abnormal neuro exam  CT/MRI - Postherpetic neuralgia
 Normal neuro exam  LP - Systemic diseases
Progressive over hours or days - Cervical spine disease
- Trauma?  subdural hematoma (CT scan) - Cerebrovascular disease
o Rule out epidural/subdural hematoma especially with - Parkinson’s disease
neurologic deficits - Exertional headache caused by angina
- No trauma
o Rigid neck  CT scan  LP (meningitis, cerebellar tumor, SYMPTOMS THAT SUGGEST A SERIOUS UNDERLYING DISORDER
slow bleed from ruptured aneursm) - Worst headache ever! – characteristic of subarachnoid
o Supple neck? haemorrhage and ruptured aneurysm
 Normal neuro exam  medical history (temporal - First severe headache
arteritis, Connective tissue disease (SLE), first attack of - Subacute worsening over days or weeks
tension or migraine headache, recent dental work-up - Abnormal neurologic examination
 Abnormal neuro exam  full neuro evaluation - Fever or unexplained systemic signs
Slowly progressive over weeks or months? - Known systemic illness
- Progressive? - Onset after age 55 years
o Other symptoms? Due to ↑ ICP:
 Absent (sinus disease, Hypertension, Connective tissue - Vomiting precedes headache
disease - Activities that ↑ CIP: bending, lifting, coughing
 Present (full neuro exam) - Disturbs sleep or presents immediately upon awakening
- Recurrent  Check symptomatology
o Not worsening  primary headache SERIOUS CAUSES
o Unilateral  classic migraine, temporal arteritis, TMJ DS - Vascular disorders
o Bilateral o Cerebral infarction
 GEN or FT  Throbbing (Common migraine), tight o Intracranial haemorrhage
pressure (tension HA) o Ruptured AV malformation
 Neck occiput (Cervical spondylosis or tension) o Ruptured AV malformation
o Ruptured IC aneurysm
HEADACHE IN CHILDREN o Temporal arteritis
- Have difficulty expressing their intent - Tumors
o We should be one-step ahead in the work-up - CNS infections
- Traumatic brain injury
ALL CAUSES OF ADULT HEADACHE EXCEPT
- Retrobulbar neuritis INTRACRANIAL HEMORRHAGE
- Glaucoma - Nuchal rigidity and headache
- Temporal arteritis - May have sensorial change or seizures
- Cervical spondylosis - Cranial CT Scan or MRI
Most common: headache accompanying any febrile illness or infection - Lumbar puncture if subarachnoid haemorrhage is suspected
of the nasal passages/sinuses o Irritates meninges  headache
- More likely rule out meningitis or encephalitis
Note: AV Malformation
- Do not take it lightly - Steals blood supply from other parts of the brain
- The younger the child, the more likely the presence of an organic - Also acts as a mass  ↑ICP
disease
- If febrile, rule out meningitis, encephalitis, or brain abscess TEMPORAL ARTERITIS
- Rule out intracranial tumors - Unilateral pounding headache
- Generally in older patients (>50 years old)
INDICATIONS FOR CT SCAN IN A CHILD WITH UNEXPLAINED - Elevated ESR usually >50
HEADACHE - Visual changes
- Acute presentation - Gold standard: Arterial biopsy
- Children <2 y.o. with rapidly increasing HC American College of Rheumatology 1990 Critera
- Progressively increasing severity - Age at least 50 years
- Decline in school performance/personality change - New onset of localized headache
- Age under 5 years - Temporal artery tenderness or decreased pulse
APPROACH TO PATIENTS WITH HEADACHE 5
- ESR of at least 50mm/hr
- Positive histology
- 3 or more of the 5 – 93.5% sensitivity & 91.2% specificity

TUMORS
- Prostrating pounding headaches
- Nausea and vomiting
- Mental status changes
- Focal neurologic deficits
- May have sensorial changes

CNS INFECTIOSN
Meningitis
- Neck rigidity
- Headache
- Photophobia
- Lumbar puncture
- CT scan/ MRI if indicated
Encephalitis
Etc

TRAUMATIC BRAIN INJURY

Acute Subdural Hematoma
Glaucoma
- Severe eye pain
- Nausea and vomiting
- Painful and red eye
- Pupil may be partially dilated
- Work patient up if serious causes are highly possible or cannot be
ruled out

UPDATE
- Anti-convulsant is given for prophylaxis
o Topiramate – accused of causing neurologic deficits when
used as prophylaxis  study proved it is not the case
- Why sex is better headache cure rather than painkillers?
o If done properly can induce release of endorphins