Headache and Dizziness/Vertigo

Surat Tanprawate, MD, MSc(Lond.), FRCPT Division of Neurology Chaing Mai University

15/13/2011

Outline of headache
Why we got headache? The headache classication Headache approach Common headache diagnosis

The Headache, George Cruikshank (1819)

Why we got pain?

Pain is a defensive mechanism of our organ from injury.

Ren Descartes, French Philosopher

31 March 1596 11 February 1650

Scalp, galea (epicranial aponeurosis), fascia, muscles: --150 observations, 30 subjects --thermal,chemical, mechanical, electrical stimulation

Ventricles, aqueduct of Sylvius, Choroid plexuses --24 observations, 4 subjects --a balloon placed through a small opening into anterior horn and body of lateral ventricle Dural artery (middle meningeal artery): --96 observations, 11 subjects --stimuli: faradizing, distending, stroking, stretching, crushing

Ray and Wolff(1940)

Headache and Pain Sensitive Structure

Meninges Venous sinus Artery: -dural a. -carotid a. -basilar a. Neural structure: -glossopharyngeal n. -trigeminal n. -upper cervical n.

Why we got headache

Why we got headache

(2) (1) (3)

(1) primary (2) secondary (3) cranial neuralgia

International Classication of Headache Disorder-2004

Part 1. The primary headaches - Migraine, TTH, CH and other TACs, and other primary headache disorder Part II. The secondary headaches -Headache attributed to .... Part III. Cranial neuralgias, central and primary facial pain and other headaches
International Classication of Headache Disorder 2004

http://ihs-classication.org

Approach to Headache disorder

Patient presents with complaint of a headache

Red ag signs
(+)

Critical rst step: Hx taking, physical exam

Investigation
Red ag signs or alarming signs

Meets criteria for primary headache disorder?

(-)

(+)

Migraine headache

Tension-type headache Other (rare) headache disorder Secondary headache disorder

Cluster headache and other TACs

Alarming signs and symptoms

Alarming s/s suggest the possibility of

secondary headache

The studies Headache sample (specic or nonspecic)

Pool analyzed data => guideline

Abnormal neurological examination Normal neurological examination

Age Temporal prole
Worsening headache -Mass lesion, SDH, MOH

Focal neurologic s/s other than typical visual or sensory aura Papilledema Neck stiffness

Concurrent event

Provoking activity

Age> 50

Sudden onset -SAH, ICH, mass lesion (posterior fossa)

Pregnancy, post partum -Cerebral vein thrombosis, carotid dissection, pituitary apoplexy

Triggered by cough, exertion or Valsava -SAH, mass lesion

Headache with cancer, HIV, systemic illness (fever, arteritis, collagen vascular disease)

Worse in the morning -IICP

Worse on awakening -Low CSF pressure

Migraine

Unilateral Throbbing
Blur vision

Nausea
Sensitive to light

The Classic Migraine = Migraine with aura

Population-based study
Only migraine without aura Only migraine with aura Both types

2 major type of migraine

- Migraine with aura - Migraine without aura

14% 19% 67%

Migraine without aura is more common (previously called common migraine)

Launer LJ et al. Neurology 1999;53:537-42

Migraine without aura

Migraine with typical aura needs 2 attacks

ICHD-II Cephalalgia.2004

Migraine Aura
99% 31%

Typical aura: -Visual -Sensory -Speech

6%

18%

n=163
Michael B. R. et al. Brain 1996: 119, 355-361

Teichopsia
(Greek for town wall vision)

On a distinct form of transient hemiopsia by Dr. Hubert Airy in 1870.

Prevalence of Migraine

Incidence of migraine by age and sex

Adjusted prevalence of migraine by geographic area and meta-analysis of studies using IHS criteria

Steewart WF. Am J Epidemiol.1991;134:1111-1120

Clinical Picture
Genetic
Trigger factors

Environmental factors Migraine attack

Migraine triggers
Diet
Chronobiologic

Hunger Alcohol Additives Certain foods

Sleep (too much or too little) Schedule change

Physical exertion

Exercise Sex

Environmental factors

Hormonal change

Menstruation

Light glare Odors Altitude Weather change

Stress and anxiety Head trauma

Tension-type headache

Tension-type headache

Most common headache type Featureless headache, uncertain pathophysiology (mental or muscular cause?) HRQoL of Headache

ETTH > CTTH = EM > CM/TM

When migraine become chronic, the headaches characters are similar to TTH

TTH diagnostic criteria

Trigeminal autonomic cephalalgia; Cluster headache

Excruciating headache

Unilateral headache

Short lasting (<180 hours)

Unilateral autonomic symptoms

Cluster headache
Cluster headache and others TACs

Short lasting, unilateral, severe headache accompanying with autonomic symptoms

ICHD-II Cephalalgia.2004

Cranial neuralgias

Cranial Neuralgias
The presence of sudden, sharp, aching,
lancinating, burning, and stabbing pain lasting from only a few seconds to less than 2 min and recurring repeatedly within short periods of time, which is often triggered by sensory or mechanical stimuli

ICHD-II, 2004

Trigeminal Neuralgia

70% of patients are older than 60 years at onset Clinical hallmark:

brief electric shock-like pains abrupt in onset and termination limited to the distributions of the trigeminal nerve commonly stimuli: mechanical

Classical trigeminal neuralgia

Symptomatic trigeminal neuralgia

TN caused by a demonstrable structural lesion

Vertigo/Dizziness

Introduction
is a very common problem in clinical
practice

The overall incidence of dizziness,

vertigo, and imbalance is 5-10%, and it reaches 40% in patients older than 40 years

Vertigo is...
an illusion of movement of body or environment; spinning, rotating, moving
vestibular disorder

Dizziness is...
very broad term...feeling off balance, rocking sensation, lightheadedness
disease of vestibular system (non-acute stage), psychogenic disorder, general medical condition

Syndrome of vertigo: base on connection

Major symptoms Vertigenous sensation Imbalance Nystagmus and oscillopsia Autonomic dysfunction
N/V Palpitation Fluctuation in BP

Psychiatric symptoms: Fear Anxiety Hyperventilation syndrome Phobia

peripheral vs central vertigo

peripheral CNS exam/symptom Auditory exam/ symptom Unsteadiness - acute - chronic Eye movement Vertigo - acute -chronic Frequently+ central +/+++ Usually+++ +++ Usually abnormal

+++ +/Normal

+++ +/-

++ +/-

Causes of vertigo
Peripheral vertigo
Infection/inammation
Peripheral vestibulopathy
Vestibular neuritis, acute neurolabyrinthitis Localized: CN7+8 affected: Ramsay Hunt syndrome Systemic: mump, measle, IM, URI

Trauma: post-traumatic vertigo Local tumor Vascular: rare Metabolic/ toxic

Aminoglycoside(rare)

Central vertigo Common is Tumor: CP angle tumor Demyelinating: MS Vascular: ischemia(VBI) Posterior fossa lesion Migraine Vertigenous epilepsy

Other: BPPV, Menieres disease

Systemic causes of vertigo and dizziness

Drugs
AED, hypnotic, alcohol, analgesic

Hypotension, presyncope Infectious disease

Syphilis, viral, systemic infection

Endocrine disease
Diabetes, hypothyroidism

Vasculitis Others: hematological, granulomatous disease, systemic toxin

Time course-onset
Lasting for day or longer Peripheral: vestibular neuritis Central: brainstem stroke, MS Lasting for hours or minute Peripheral: Menieres disease Central: TIA, migraine, seizure Lasting for second Peripheral: BPPV

Surat Tanprawate, MD, MSc(Lond.), FRCP(T) CertHE(Hist Med) Neurology staff, Division of Neurology, CMU The Northern Neuroscience Center, CMU

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