Lecture 7b

Headache
Dr\ Tarek Ragab

By the end of the lecture the student will be able to

• Describe extracranial and intracranial pain sensitive structures. -Identify
migraine, its pathogenesis, biochemical basis, predisposing factors, role of
psychological factors and endocrine and metabolic factors.
• Describe clinical picture of migraine and how to manage migranous headache.
• Describe clinical picture of tension headache,cluster headache and management.
• Identify manifestation of increase intracranial tension headache and pseudotumor
cerebri and management.

INTRODUCTION
• Most common of all human physical complaints
• Despite regional variations, headache disorders are a worldwide problem, affecting
people of all ages, races, income levels, & geographical area
• Headache is a painful and disabling feature , and are the most common disorder of the
nervous system.
Definition
• A headache is a pain or discomfort in the head, scalp, or neck. The major types are
− Primary Headache
− Secondary Headache

Primary Headache
• A primary headache is due to the headache condition itself and not due to another cause.
• Types of primary headache are
– Migraine
– Tension Type
– Cluster
– Other types

Migraine headache
• Considered as vascular headache
• Migraine type of headache occurs more in females then males
• Migraine headache is a benign and recurrent syndrome of headache, nausea/vomiting,
and other varying neurologic dysfunction.
• Pulsatile, throbbing, unilateral or bilateral , and aggravated by minor movement
• Present with photophobia and phonophobia
• Attack duration: 4–72 hours

Etiology
• Hormonal changes in women.
– Fluctuations in estrogen, such as before or during menstrual periods, pregnancy
and menopause

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 – Hormonal medications, such as oral contraceptives and hormone replacement
therapy
• Drinks. These include alcohol, especially wine, and too much caffeine, such as
coffee.
• Stress. Stress at work or home can cause migraines.
• Sensory stimuli.
– Bright lights and sun glare can induce migraines, as can loud sounds.
– Strong smells — including perfume, paint thinner, secondhand smoke
• Sleep changes. Missing sleep, getting too much sleep
• Physical factors. Intense physical exertion, including sexual activity, might
provoke migraines.
• Weather changes. Barometric pressure can prompt a migraine.
• Medications. Oral contraceptives and vasodilators, such as nitroglycerin.
• Foods. Aged cheeses and salty and processed foods, skipping meals or fasting.
• Food additives. Sweetener aspartame and the preservative monosodium glutamate
(MSG)
Types
• Migraine without aura (more common 80%) is a migraine without a preceding
focal neurologic deficit.
• Migraine with aura (classic migraine) is accompanied by a preceding aura that
consists of motor, sensory, or visual symptoms. Focal neurologic symptoms
usually occur during the headache rather than as a prodrome. The pathognomonic
aura for classic migraine is the scintillating scotoma. Visual auras are also
described as stars,

Pathophysiology
Presymptomatic hyperexcitabilty increases brain stem response
to triggers

Release of Neurotransmitters (5-HT, NE, DA, GABA,

Glutamate, NO, CGRP, Substance P, Estrogen)

Neurotransmitters activate the Trigeminal Nucleus

Activation of Activation of Activation of Dilation of

Hypothalamus Area Postrema cervical trigeminal Meningeal blood
(Hypersensitivity) system (Muscle vessels
spasm) (Throbbing)

Activation of Cortex and

Thalamus (Head pain)

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 Other types
• A silent or acephalgic migraine: it is a migraine without head pain but with aura
and other aspects of migraine.
• A hemiplegic migraine: This can have symptoms that mimic a stroke, such as
weakness on one side of the body, loss of sensation, or feeling "pins and needles.
• “Basilar migraine is migraine associated with symptoms consistent with
brainstem involvement (vertigo, diplopia, ataxia, or dysarthria).
• Complicated migraine is migraine with severe neurologic deficits that persist
after the resolution of pain.
• Chronic migraine: It is a migraine headache that lasts for more than 15 days per
month for three consecutive months.
• Status migrainosus: it is a constant migraine attack that lasts morethan 72 hours.

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 Management
Migraine headache
• Acute episode (abortive therapy)
– Triptans, serotonin receptor agonists (sumatriptan is first-line)
– Dihydroergotamine
– Ergotamine, used in combination with caffeine and non steroidal analgesics,
for acute abortive therapy
– Dopamine antagonists such as metoclopramide: given orally they help
absorption of other medications, and when given parenterally they provide fast-
acting relief for migraine

• Prophylaxis (for acute migraine headache >3–6/month)

− Beta blocker: propranolol, valproic acid, and topiramate (all first-line)
− Verapamil and tricyclics (require 2–6 weeks for full effect)
− SSRIs such as sertraline and fluoxetine
− Calcitonin gene related peptide CGRP monoclonal antibodies for resistant
cases

Tension headache:
• Is the most common type of head ache , is characterized by bilateral location. It is
usually mild or moderate intensity and not aggravated by physical activity. Tension
type headache is sub categorize as
− Infrequent episodic
− Frequent episodic
− Chronic

Etiology
• It caused due to sustained pain full contraction of the muscles of the scalps and
neck
• Physical or emotional stress
• Alcohol use
• Caffeine (too much or withdrawal)
• Colds, the flu, or a sinus infection
• Dental problems such as jaw clenching or teeth grinding
• Eye strain
• Excessive smoking
• Fatigue or overexertion

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 Clinical manifestation
• The headache pain may be • Pain may last for 30 minutes to 7
described as: days. It may be triggered by or get
• Dull, pressure-like (not throbbing) worse with stress, fatigue, noise, or
• A tight band or vise on or around glare.
the head • There may be difficulty sleeping.
• All over (not just in one point or one • People with tension headaches try to
side) relieve pain by massaging their scalp,
• Worse in the scalp, temples, or back temples, or the bottom of the neck.
of the neck, and possibly in the • Sleep disturbances
shoulders • Photophobia – sensitivity to light
• The pain may occur once, • Phonophobia – sensitivity to sound
constantly, or daily.
Management
• Over-the-counter (OTC) pain medicines, such as aspirin, ibuprofen, or
acetaminophen
• Narcotic pain relievers are generally not recommended
• Muscle relaxants
• Tricyclic antidepressants to prevent recurrences

Health Education
• Keep warm if the headache is associated with cold.
• Use a different pillow or change sleeping positions.
• Practice good posture when reading, working, or doing other activities.
• Exercise the neck and shoulders frequently when working on computers or
doing other close work.
• Get plenty of sleep and rest.

Cluster headache:
• Cluster headache (men > women) begins without warning.
• Excruciating, unilateral, periorbital
• Peaks in intensity within 5 minutes of onset
• Rarely pulsatile in nature
• Lasts from 30 minutes to 3 hours, and occurs 1–3 times per day for 4–8 weeks
• Symptoms include rhinorrhea, reddening of the eye, lacrimation, nasal stuffiness,
nausea, and sensitivity to alcohol.
• Horner syndrome may be seen.
• Emotion and food will rarely trigger a cluster headache

Types
• There are two types of cluster headaches: episodic and chronic.
• Episodic cluster headaches occur regularly between one week and one year, followed
by a headache-free period of one month or more.
• Chronic cluster headaches CCH occur regularly for longer than one year, followed by
a headache free period that lasts for less than one month.

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Medication
• Pain medication relieves your headache pain once it has begun. Treatments include:
• Oxygen: Breathing 100-percent pure oxygen when the headache begins can help
relieve symptoms.
• Triptan medications: A nasal spray medication called sumatriptan (Imitrex), or other
tripitan medications constrict blood vessels, which can help ease your headache.
• DHE: An injected medication called dihydroergotamine (DHE), can often relieve
cluster
• headache pain within five minutes of use. Note: DHE can’t be taken with sumatriptan.
• Blood pressure medications, such as propranolol or verapamil which relax your blood
vessels
• Capsaicin cream: Topical capsaicin cream can be applied to the painful area.

CCH (prophylaxis);
− Prednisone and
− Antidepressant medications
− Anti-seizure medications, such as topiramate and valproic acid
− lithium are alternatives

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Secondary Headache
• A secondary headache is present because of another condition. The management of
secondary headache focuses on diagnosis and treatment of the underlying condition.
The types of secondary headache are
– Systemic infection E.g. Meningitis,
– Head injury
– Vascular disorders E.g. Aneurysm Rupture, Stroke
– Subarachnoid hemorrhage
– Brain tumor

• The most important question to answer with a complaint of headache is whether a

serious underlying cause exists for the symptoms. Do this with a thorough history and
physical examination.
• Is this the patient’s first episode of headache? A history of recurrent symptoms
• suggests a primary headache disorder, while a first-time headache— especially severe
• and rapidly peaking—suggests a serious underlying pathology.
• Once serious underlying pathology is excluded by history and physical examination,
consider a primary headache syndrome: migraine, tension, or cluster headache.

Headache with fever and nuchal rigidity suggests meningitis.

Headache described as “the worst headache of my life” and/or an intracranial

“thunderclap” at onset, accompanied by nuchal rigidity without hemorrhage.
fever, suggests
Headache described as a deep, dull, aching pain and that disturbs a brain tumor.
sleep suggests
A history of vomiting that precedes the onset of headache by a a posterior
number of weeks, or a history of headache induced by coughing, fossa brain
lifting, or bending, suggests tumor.

History of eye pain preceding the onset of headache suggests glaucoma.

Temporal arteritis
Unilateral pounding headache associated with visual changes described as dull and boring
with superimposed lancinating pain suggests temporal arteritis.
• Commonly seen age >50
• Symptoms also include polymyalgia rheumatica, jaw claudication, fever, weight loss,
and scalp tenderness (difficulty combing hair/lying on a pillow) (scalp tenderness is
due to pain over the temporal artery). º Causes sedimentation rate to elevate ESR º
Diagnosed with biopsy of the temporal artery

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Raised Intracranial Pressure (ICP)
Clinical manifestation of generalized increased ICP:
A. Headache: is mainly due to compression or distortion of the dural matter and of the
pain sensitive blood vessels. It is often paroxysmal, worse in the morning, bursting in
character and is accentuated by exertion, coughing, sneezing, and straining or sudden
change in posture and relieved by dehydrating measures and analgesics. The headache
is often frontal or occipital or both.
B. Vomiting: often occurs in the morning when the headache is at its maximum, usually
not related to meals and may have a projectile character (not preceded by nausea)
especially in children. It is generally attributed to compression or ischemia of the
medullary
C. Papilloedema causing blurring of vision, commonly appears with rapid increase of
ICP or with lesions of the posterior fossa.
D. Bradycardia and raised systemic blood pressure, but tachycardia may develop.
E. Disturbed level of consciousness, starting from drowsiness in moderate cases to
coma and death in case with severe rise in ICP.
F. convulsions may occur
G. Respiration is normal or rapid in early stages of raised ICP then become slow and
deep respiration, later may become irregular with periods of apnea (Chyne-Stockes
respiration).

NB: Headache, vomiting and papilloedema are the most common manifestations
of generalized increased intracranial pressure

Causes of raised intracranial pressure:

1. Neoplasm (Primary or secondaries).
2. Cerebrovascular stroke (massive hemorrhage, subarachnoid hemorrhage and
massive infarction).
3. Infection (meningites, brain abscess and encephalitis).
4. Hydrocephalus.
5. Trauma (concussion or contustion).
6. Benign intracranial hypertension
7. Systemic causes: e.g; electrolytes imbalance and metabolic encephalopathies.

Treatment:
• Dehydrating measures: to decrease brain edema by using mannitol 25% (1-
2gm/kg/day) for 2 days, corticosteroids (16-32mg dexamethazone/day), diuretic
and/or glycerine.
• Dealing with the cause.

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Benign Intracranial Hypertension (Pseudotumor Cerebri)
• Pseudotumor cerebri (or benign intracranial hypertension) is an idiopathic increase in
intracranial pressure.
• Women > men by 10×.
• Often there is no identified cause and the disorder resolves spontaneously after several
months.
• There is an association with obesity, chronic lung disease, Addison disease, oral
contraceptives, tetracycline use, and vitamin A toxicity.

Symptoms include:
• Headache
• Visual disturbances such as diplopia and papilledema; enlargement of the blind spot
on visual field testing
• Sixth cranial nerve (abducens) palsy
• Normal CT, MRI, and CSF beyond an increase in pressure

Treatment.
• Weight loss
• Removal of the offending agent, e.g., oral contraceptives
• Diuretics such as acetazolamide and furosemide
• Steroids such as prednisone
• For urgent cases, repeated lumbar punctures
• If there is no response, possible placement of a surgical shunt between the ventricles
and peritoneum

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