CD B [PD]: NEUROLOGY - HEADACHE

DR. BARJA – FEB. 2018

PAIN PAIN INSENSITIVE CRANIAL STRUCTURES

 An unpleasant sensory and emotional experience associated  Includes:
with actual or potential tissue damage, or described in terms of  Brain parenchyma
such damage  Ependyma
 Choroid plexus
HEADACHE  Pia matter
 Pain located above the orbitomeatal line  Arachnoid
 All aches and pains located in the head  Dura over convexity of skull
 Discomfort in the region of the cranial vault  Dura around vascular sinuses and vessels is sensitive
 Face and scalp are more richly supplied with pain receptors to pain
 Many are due to medical rather than neurologic diseases
 Always a question if there is an underlying intracranial disease APPROACH TO HEADACHE
 Most common reason for seeking medical help HISTORY
 Know precipitating /palliative factors
 Relationship of HA to certain biologic events (ex: menstrual
cycle)
 Relationship to aggravating or relieving factors (ex: lying
down, noisiness)

PRECIPITATING FACTORS POSSIBLE DIFFERENTIAL

Premenstrual period  Premenstrual tension
headache
 Migraine
 Anterior cranial fossa: contains the frontal lobe Intense pain after periods of  Cervical spine disease
 Middle cranial fossa: contains temporal and parietal lobe inactivity, 1st movements are
 Posterior cranial fossa: contains the cerebellum and brain stiff / painful
stem Upon awakening, mid-  Nasal sinusitis
morning, worse on stooping,
 Nerves in the head originates from the trigeminal nerve
changes in atmospheric
(CN5)
pressure
Prolonged eye use, peering  Eyestrain headache
into glaring lights
Headache made worse on  Intracranial (distension of
sudden movement or by vessels)
coughing/straining, exertion
Induced by anger, excitement,  Migraine
worry
Stroking of hair  Temporal arteritis
Extreme rise in BP  Pheochromocytoma
 Malignant HPN
PAIN SENSITIVE CRANIAL STRUCTURES
 Includes: LOCATION
 Intracranial venous sinuses and tributaries (pericavernous)
 Parts of dura at base of brain, arteries w/n dura and pia-
arachnoid
 Middle meningeal, superficialtemporal arteries
 Cranial nerves II, III, V, IX, X and cervical nerves I-III
 Skin, SC tissue, muscles, extracranial arteries, periosteum of
the skull
 Delicate structures of eye, ear, nasal cavities, paranasal
sinuses
 Pain arises in walls of small blood vessels containing pain fibers

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CD B: PD | NEUROLOGY - HEADACHE
DR. BARJA – FEB. 2018

Inflammation of extracranial
artery
Paranasal sinus HA, or HA from
teeth, eyes, upper cervical
vertebra
Intracranial lesions
Posterior fossa
Supratentorial
Non-specific
Glaucoma, sinusitis, throm-
bosis of VA, BA pressure on
tentorium, Increased ICP
Ear disease
Disease of throat, cervical
spine, posterior fossa
Eye disease, dissection of
cervical ICA
Sphenoid/ethmoid sinus
disease, thrombosis of
superior sagittal sinus
LOCATION
 Localized to site
 Not sharply localized but
occur in specific regions:
forehead, maxilla, around
the eyes
 Occipitonuchal
 Fronto-temporal approx-
imating site of lesion
 Frontal region pain
TEMPORAL PROFILE
 Ear pain
 Mode of onset: is it a sudden headache?
 Time-intensity curve
 Peri-orbital  Duration
 Supraorbital
 Vertex
 Bi-parietal

QUALITY
 Most headaches are dull, aching, not sharply localized
(regardless of type)
 Tightness, Pressure, bursting

QUALITY
Pricking or stinging  Skin
Throbbing  Vascular source TEMPORAL PROFILE
 Migraine if hemicranial Abrupt, maximal severity in  Subarachnoid
seconds/minutes hemorrhage
 Referred pain Gradually over hours/days  Meningitis
 Pain from supratentorial structures referred to: territory of Onset in early am/daytime,  Classic migraine
CN V (1st and 2nd division) peak over 30 minutes, lasts 4-
 Pain from infratentorial structures referred to: vertex, back 72 hrs unless treated, and
terminated by sleep
of head and neck
Any time, interrupts sleep, vary  Tumors
in intensity, few minutes/hours
SEVERITY Worse on awakening  Posterior fossa tumor
 Interpret with caution
 Not all painful headaches are dangerous (ex. Migraine)  HA that have recurred regularly for many years prove to be
 What may be painful to one might not be painful to another VASCULAR or tension type
 Index of severity: degree to which HA has incapacitated the
patient NEURO EXAMINATION
 Affects ADL’s
 Signs and symptoms of increased intracranial pressure
 Awakens from sleep
 Signs and symptoms of meningeal irritation
 Prevents sleep
 Focal neurologic deficits
 Most intense pain
 Deadly: meningitis, subarachnoid hemorrhage
 Benign: migraine, cluster, tic doloreaux

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CD B: PD | NEUROLOGY - HEADACHE
DR. BARJA – FEB. 2018

INCREASED ICP FOCAL NEUROLOGIC DEFICITS

 Symptoms:  Mental status
 Headache  Cranial nerves
 Vomiting  Motor
 Papilledema: swelling of the optic disc and anterior bulging  Cerebellar
of the physiologic cup  Sensory
 Diplopia with internal squint (lateral rectus palsy): due to
impingement of the cranial nerve 6 DIFFERENTIAL DIAGNOSIS
 Deterioration in the level of consciousness
 Eye problem?
 Hydrocephalus: enlarging of ventricles inside the brain  Sinus?
 On ophthalmologic examination, loss of spontaneous venous
pulsation occurs with high intracranial pressures (above 190 mm
HEADACHE AND EYE DISORDERS
H2O)
 Eye disorders known to be associated with headache or ocular
pain:
 Acute glaucoma
 Uveitis
 Optic neuritis
 Ophthalmologists are the 3rd most often consulted specialists
for acute headaches
(2nd pic: papilledema; 3rd pic: severe papilledema with hemorrhages)

SINUSITIS
 Do physical examination for sinusitis
 Transillumination of frontal and maxillary sinuses
 Tenderness on percussion or compression over the frontal
and maxillary sinuses and mastoid processes
(lateral rectus palsy)  Valsalva maneuver
 Increases sinus pain, which will then have a pounding
MENINGEAL IRRITATION character corresponding with the pulse
 Headache  Increased venous pressure acting on the swollen
 Vomiting mucosa
 Nuchal rigidity
 Brudzinski’s neck sign PRIMARY HEADACHES
 As you flex the neck, watch the hips and knees in reaction
to your maneuver.
 Normally they should remain relaxed and motionless
 Flexion of both the hips and knees is a positive Brudzinski
sign
 Kernig’s sign
 Flex the patient’s leg at both the hip and the knee, and then
slowly extend the leg and straighten the knee MIGRAINE HEADACHE
 Discomfort behind the knee during full extension is normal  3rd most prevalent disorder and seventh-highest specific cause
but should not produce pain of disability worldwide
 Pain and increased resistance to knee extension are a  Headache associated symptoms of migraine
positive Kernig sign.  Symptoms before the headache begins
 Symptoms associated with the headache
 Symptoms after the HA resolves
 Two major subtypes
 Migraine without aura – “sasakit nalang bigla yung ulo”
 Migraine with aura
 Transient focal neurological symptoms that usually
precede or sometimes accompany the headache

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CD B: PD | NEUROLOGY - HEADACHE
DR. BARJA – FEB. 2018

PREMONITORY AND RESOLUTION SYMPTOMS AURA

 Hyperactivity, hypoactivity
 Depression
 Cravings for particular foods
 Repetitive yawning
 Fatigue
 Neck stiffness / pain
MIGRAINE WITHOUT AURA: DIAGNOSTIC CRITERIA
 At least five attacks fulfilling criteria B–D
 Headache attacks lasting 4-72 hours (untreated or
unsuccessfully treated)
 Headache has at least two of the following four characteristics:
 Unilateral location
 Pulsating quality
 Moderate or severe pain intensity
 Aggravation by or causing avoidance of routine physical
 During headache at least one of the following:
 Nausea and/or vomiting
 Photophobia and phonophobia
 Not better accounted for by another ICHD-3 diagnosis
 Often bilateral in children and adolescents (< 18 y/o)
 Unilateral in late adolescence or early adult life
 Usually frontotemporal
 Some have facial location of pain, which is called ‘facial migraine
 Often has a menstrual relationship
 The disease most prone to accelerate with frequent use of
symptomatic medication (medication overuse HA)
MIGRAINE WITH AURA: DIAGNOSTIC CRITERIA
 At least two attacks fulfilling criteria B and C
 One or more of the following fully reversible aura symptoms:
 Visual
 Motor
 Sensory
 Brainstem
 Retinal
 Speech and/or language
 At least two of the following four characteristics:
 At least one aura symptom spreads gradually over > 5
minutes, and/or two or more symptoms occur in succession
 Each individual aura symptom lasts 5-60 minutes
 At least one aura symptom is unilateral
 The aura is accompanied, or followed within 60 minutes, by
headache
 Not better accounted for by another ICHD-3 diagnosis, TIA has
been excluded
 Complex of neurological symptoms that occurs usually before
the HA ---may begin after the pain phase has commenced
 Visual aura
 Most common type of aura;
 > 90% of patients aura
 Scintillating scotoma /fortification spectrum
 Also called visual migraine
 The most common visual aura preceding migraine
 Can also occur acephalgically (without headache)
 As the scotoma area expands, some people perceive
only a bright flickering area that obstructs normal
vision, while others describe seeing various patterns.
 Some describe seeing one or more shimmering arcs of
white or colored flashing lights.
 An arc of light may gradually enlarge, become more
obvious, and may take the form of a definite zigzag
pattern, sometimes called a fortification spectrum (i.e.
teichopsia) aura
 Sensory disturbances
 Pins and needles affecting one side of the body, face
and/or tongue
 Numbness
 Speech disturbances, usually aphasic
 Motor weakness
 Hemiplegic migraine, may last for weeks
MIGRAINE WITH AURA: BRAINSTEM SYMPTOMS
 Dysarthria
 Vertigo
 Tinnitus
 Hypacusis
 Diplopia
 Ataxia
 Decreased level of consciousness
Many patients who have migraine attacks with aura also have
attacks without aura migraine aura may occur without headache
When will you suspect transient ischemic attack?
 When aura occurs for the first time after age 40
 When symptoms are exclusively negative (e.g. hemianopia)
 When aura is prolonged or very short
CHRONIC MIGRAINE
 Headache occurring on 15 or more days per month for > 3
months, which has the features of migraine headache on at least
8 days per month

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CD B: PD | NEUROLOGY - HEADACHE
DR. BARJA – FEB. 2018

TENSION HEADACHE ACUTE MIGRAINE TREATMENT

 General principles
 Very common
 Treat as early as possible to reduce intensity and duration
 Lifetime prevalence in the general population 30-78%
of attack
 Very high socio-economic impact
 GOAL: free of migraine within 2 hrs, no recurrence for
 Typically bilateral, pressing or tightening, mild to moderate
at least 24 hrs
severity
 Tailor the treatment to the patient and the migraine attack
 Lasting 30 min to 7 days
 Does not worsen with routine physical activity
 Not associated with nausea
 Photophobia or phonophobia may be present
 Infrequent episodic tension-type headache
 Occurs in almost the entire population
 Has very little impact on the individual, requires no medical
attention Drugs: Muscle Relaxant

 Frequent episodic tension-type headache

 Associated with considerable disability,
 Sometimes warrants treatment with expensive drugs

CLUSTER HEADACHE
 When given during an aura, triptans do not show consistent
 Acute attacks involve activation in the region of the posterior efficacy in aborting or preventing the migraine
hypothalamic grey matter  Non-specific pain medicines
 Age at onset is usually 20–40 y/o  NSAIDs
 3x more in men  Combination analgesics
 May be autosomal dominant in about 5% of cases  Opioids
 May be provoked by alcohol, histamine or nitroglycerin  Neuroleptics / anti emetics
 Corticosteroids
CLUSTER HEADACHE: DIAGNOSTIC CRITERIA  Specific pain medicines
 At least five attacks fulfilling criteria B–D  Triptans
 Severe or very severe unilateral orbital, supraorbital and/or  Ergotamine / DHE
temporal pain lasting 5–180 minutes (when untreated)  Principles for Prophylactic treatment
 Either or both of the ff:  Frequency of attack > 2 per month
 At least one of the following symptoms or signs, ipsilateral  Symptoms significantly interferes with ADLs even w/ acute
to the HA treatment lasting > 3 days/ month
 Conjunctival injection and/or lacrimation  Failure, A/E and c/i of acute therapies
 Nasal congestion and/or rhinorrhoea  Overuse of acute therapy ie > 2x per wk
 Eyelid oedema  Patient preference
 Forehead and facial sweating  Choice of drug: co-morbidities, A/E, interactions
 Forehead and facial flushing  Considered successful if > 50% decreased frequency of
 Sensation of fullness in the ear attack per month w/in 3 months
 Miosis and/or ptosis  Continued for 4-6 months then taper over 2-3 weeks
 A sense of restlessness or agitation

APPROACH TO TREATMENT OF PRIMARY HEADACHES

MIGRAINE
 Acute treatment: to stop pain and prevent progression
 Preemptive treatment: avoidance of known headache triggers
 Preventive treatment: maintenance meds x months-years to
reduce attack frequency, severity, duration

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CD B: PD | NEUROLOGY - HEADACHE
DR. BARJA – FEB. 2018

CLUSTER HEADACHE
 Acute treatment
 SC sumatriptan (6 mg) fastest,
 Intranasal sumatriptan (20 mg), zolmitriptan (5 mg)
 Intranasal lidocaine 4%
 O2 inhalation (10-15 LPM) x 15 minutes
 Prescription analgesics or opioids not effective and may
lead to medication overuse HA
 Transitional treatment (1-2 weeks)
 Prednisone 60 mg qd x 3 days, then taper by 10 mg q 3
days
 Ergotamine
 Occipital nerve blockade
 Maintenance (duration of cluster period, usually 2-3 mos)
 Verapamil 80 mg TID or 240 mg SR up to 720 mg/day
 Valproic acid 500-2000 mg/d
 Topiramate 50-150 mg/d
Valproate ER Topiramate
500-1000 mg 50-200 mg TENSION HEADACHE
Average migraine Decreased 1.8x Decreased 3x  Non-pharmacologic therapy
frequency
 Relaxation
HA intensity Decreased 3.7 x Decreased 3.6 x
 Stress reduction
HA duration Decreased by 13.4 Decreased 11.9 hrs
 Biofeedback
hours
 Pharmacologic
Side effects Weight gain (34%), weight loss (23%)
 TCA anti-depressants
hair loss (3%), paresthesias (9%),
somnolence (3%) somnolence, GI
intolerance SECONDARY HEADACHES
 Symptoms suggesting systemic illness
DRUGS USED COMMONLY BY DOCTORS IN PRACTICE  Neurological s/sx, focal or non-focal
MD Acute treatment Preventive  Most severe headache ever experienced
1 IV NSAIDs (ketoprofen) Anti-convulsants  Maximal severity at onset
RTC oral NSAID x 2-3 mos up to 6 mos  Persistent or progressive worsening of headache
+/- RTC round the clock
 Change in usual headache pattern awakening of patient from
tramadol/paracetamol sleep
2 NSAIDs Topiramate  New onset HA in > 50 y/o
Opioids Valproate  Valsalva maneuver precipitates HA
Triptans  Seizures
3 NSAIDs Topiramate
Valproate
Flunarizine (Sibelium) CASES:
4 NSAIDs Topiramate 78M, hypertensive on maintenance medicines
Tramadol / Valproate  Sudden severe headache, pain score: 10/10
paracetamol Flunarizine (Sibelium)  Vomiting, altered sensorium
Triptans  Emergency room:
5 Orphenadrine + Topiramate  BP 200/110
paracetamol Valproate  E3V5M6 (Glascow Coma Scale)
Sumatriptan/ Flunarizine (Sibelium)  No focal deficits
zolmitriptan  (+) nuchal rigidity
Tramadol
6 NSAIDs Anti-convulsants
Tramadol / Anti-depressants
paracetamol
Triptans

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CD B: PD | NEUROLOGY - HEADACHE
DR. BARJA – FEB. 2018

 Patient has: tumor

 Patient has: Subarachnoid hemorrhage secondary to
ruptured aneurysm
78F, hypertensive, diabetic controlled with meds
 4 days PTA- After sneezing, (+) severe pain on the left
temple, with partial relief from analgesics
 3 days PTA- (+)diplopia
 2 days PTA- (+) ptosis left eye
 Admission
 Physical / Neuro exam
 (+) bruit -left eye, left carotid
 Left eye
 Ptosis
 Mydriasis
 (+) palsy of superior/inferior recti, medial
rectus muscle
 Patient has: Carotico-cavernous fistula
37M
 Moderate to severe headache, 8-10/10 pain score x 2
months
 Partial relief from analgesics
 Cranial CT scan: normal
 CSF analysis:
 Opening pressure > 500 mm H2O
 (+) pleocytosis, lymphocytic, low sugar
 (-) TB PCR, (-) CALAS
 Treated with quadruple anti-Koch’s
 After 1 month, still with 8-10/10 HA
 CSF analysis
 Opening pressure > 500 mm H2O
 (+) pleocytosis, lymphocytic, low sugar
 (-) TB PCR, (-) CALAS, (-) india ink
 Treated for MDR TB meningitis: quadruple anti-Koch’s,
ciprofloxacin, dexamethasone
 Fungal culture (+) after 1 month
 Advised amphotericin, but initially refused
 Consult with another neurologist, IDS
 On the 6th month
 Still with moderate to severe headache
 (+) weakness of right hand
 Consult:
 CSF analysis:
 High pressure
 (+) CALAS, (+) india ink
 Amphotericin started
 (+) seizure
 (+) deterioration in sensorium
 Repeat cranial CT scan: stroke secondary to arteritis  died

52M, hypertensive
 On and off mild-moderate-severe HA x 3 months
 Progressing severity and duration
 Partial relief from analgesics
 Progressive Left sided hemiparesis x 1 week
 (+) vomiting

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CD B: PD | NEUROLOGY - HEADACHE
DR. BARJA – FEB. 2018

RARE PRIMARY HEADACHE

 Primary headache associated with sexual activity
 Men > women
 Pain intensity may increase with increasing sexual excitement
 Abrupt explosion of intensity just before or with orgasm
 Can last 1 min to 24 hr
 Previously classified as : pre-orgasmic and orgasmic
 More prone to have abnormalities in cerebral venous circulation
(venous stenosis)
 Triptans, Propranolol and indomethacin effective as prophylaxis
 Headache more common in women?

FACTITIOUS DISORDER
 A condition in which a person acts as if they have an illness by
deliberately producing, feigning, or exaggerating symptoms

TRIGEMINAL NEURALGIA (TIC DOLOREAUX)

 3x more common in women
 > 50 y/o
 Paroxysms of intense, stabbing pain
 Patient winces involuntarily
 V2 and V3 division of CN V
 Rarely lasts more than a few seconds but recurs frequently x
several weeks at a time
 Initiation of pain by stimulation tigger points in the face, lips,
gums
 Compression of trigeminal roots by a tortous blood vessel
 Treatment:
 Carbamazepine
 Gabapentin
 Valproic acid
 Phenytoin

Note: Old ppt was used in making this trans. May isang additional
case ata siyang nilagay na wala dito.
NO PROOF READING WAS DONE, USE AT YOUR OWN RISK

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