Headache

PAIN SENSITIVE STRUCTURES

1.
2. 3.

4.
5.

Dura near vessels Cranial nerves v, vii ,ix , x Circle of Willis and proximal arteries Meningeal arteries Large veins in the brain

PAIN SENSITIVE STRUCTURES

6.
7. 8.

9.
10. 11.

Scalp and neck muscles Cervical nerves and roots Cutaneous nerves and skin Mucosa of Para nasal sinuses Teeth External carotid arteries

Major categories of headache disorders

Migraine Tension headache Cluster headache other trigeminal autonomic cephalagias Headache due to head / neck trauma. Headache due to vascular causes. Headache due to non-vascluar causes. Headache due to infection. Headache due to substance or its withdrawal. Headache due to systemic causes Headache due to psychiatric disorder. Headache due to disorder of cranium, neck,eyes, ears, nose--Cranial neuralgias and other facial pain.

Headache

Primary headache

Migraine Episodic tension type of headache Episodic cluster Trigeminal neuralgia pseudotumer cerebri Subarachnoid hemorrhage Temporal arteritis

Secondary headache

Features of migraine

Epidemiology Women/Men Family history Typical age of onset

18% women, 6% men, 9% children 3/1 after puberty, 1/1 before 80% of first degree relative 92% before age of 40 2% after age of 50

Visual aura

20%

Features of migraine

Location Quality Severity Onset to peak pain Duration

Unilateral 60%, Bilateral 40% Pulsatile or throbbing in 85% Mild to severe Minutes to hours 4-72 hours

Features of migraine

Frequency Periodicity Associated features

Rare to frequent Menstrual migraine Nausea in 90%, Vomiting in 30% Light, nose sensitivity in 80% Present in 85%, Numerous

Triggers

Awaken from sleep

Can occur

Headache

Primary headache

Migraine Episodic tension type of headache Episodic cluster Trigeminal neuralgia pseudotumer cerebri Subarachnoid hemorrhage Temporal arteritis

Secondary headache

Episodic tension type of headache

Epidemiology

90% adults 39% children ages 3-11 5/4

Women/Men

Family history
Typical age of onset

Frequent
20-40

Visual aura

No

Episodic tension type of headache

Location Quality

Bilateral, unilateral Pressure, aching, tight, squeezing Mild to moderate

Severity
hours Onset to peak pain Hours to days

Duration

Episodic tension type of headache

Frequency Periodicity Associated features Triggers Awaken from sleep

Rare to frequent No Rare nausea Stress &lack of sleep rare

Headache

Primary headache

Migraine Episodic tension type of headache Episodic cluster Trigeminal neuralgia pseudotumer cerebri Subarachnoid hemorrhage Temporal arteritis

Secondary headache

Episodic cluster

Epidemiology Women/Men Family history Typical age of onset Visual aura

0.4% for men, 0.08% for women 1/5

Rare
20-40

Occasional

Episodic cluster

Location

Unilateral (orbital, periorbital, frontotemporal) Stabbing, boring, burning

Quality

Severity
Onset to peak pain

Severe
Minutes 15-150 minutes

Duration

Episodic cluster

Frequency Periodicity Associated features

1-3 days Yes (bout : 3-4 weeks, 1-2 bouts/year Ipsilateral conjunctival injection, tearing and nasal congestion, ptosis Alcohol, nitrates

Triggers

Headache

Primary headache

Migraine Episodic tension type of headache Episodic cluster Trigeminal neuralgia pseudotumer cerebri Subarachnoid hemorrhage Temporal arteritis

Secondary headache

Trigeminal neuralgia

Epidemiology

3-4/100,000/year Female/male 1.6/1 Usually over 40

Age of onset

Location

Unilateral in 96% 2nd or 3rd >1st division

Trigeminal neuralgia

Quality& severity Frequency

Stabbing, electrical bursts, burning Few to many /day

Associated features

Trigger zone in 90%

Headache

Primary headache

Migraine Episodic tension type of headache Episodic cluster Trigeminal neuralgia pseudotumer cerebri Subarachnoid hemorrhage Temporal arteritis

Secondary headache

pseudotumer cerebri

Epidemiology

1/100,000/year 90% women, 9% obese 30 years

Age of onset

Location

Often bifronto-temporal

pseudotumer cerebri

Quality& severity Frequency Associated features

Pulsatile& moderate to severe Daily Papilledeme in 95% Tinnitus 60% Vi neuropathy 20%

Headache

Primary headache

Migraine Episodic tension type of headache Episodic cluster Trigeminal neuralgia pseudotumer cerebri Subarachnoid hemorrhage Temporal arteritis

Secondary headache

Subarachnoid hemorrhage

Epidemiology Age of onset Location

30,000/ year in us 50 years Usually bilateral, any location

Subarachnoid hemorrhage

Quality& severity Frequency Associated features

Usually severe Paroxysmal Nausea, vomiting, neck stiffness(64%) CT scan abnormal in 1st day 95% 3rd day 74% 1st week 50%

Headache

Primary headache

Migraine Episodic tension type of headache Episodic cluster Trigeminal neuralgia pseudotumer cerebri Subarachnoid hemorrhage Temporal arteritis

Secondary headache

Temporal arteritis

Epidemiology

Age >50 18/ 100,000/ year Female/ male =3/1 Rare before 50 Unilateral or bilateral Temporo-frontal

Age of onset Location

Temporal arteritis

Quality& severity

Throbbing, sharp Mild to severe Intermittent to continuous

Frequency

Associated features

50% have PMR 38% jaw claudication

IHS classification of migraine

Migraine without aura

Migraine with aura

Typical aura FHM

Basilar type migraine

Complication of migraine

Chronic migraine

Status migrainosus

Migrainous infarction

Pathophysiology of migraine
Genetic predisposition Channelopathy

Cortical neuronal hyper excitability Cortical spreading depression Brain stem activation

Trigeminal vascular activation

Phases of migraine
1.

Prodroma
Aura Headache phase

2.

3.

4.

postdroma

Phases of migraine attack

1- prodrome [ hypothalamic ] 2- aura [ spreading depression ] 3- headache [ trigemino-vascular system ] 4- postdrome [ sterile inlammatory ]

Treatment of acute attack of migraine

I.

Non specific
Acetaminophen prostaglandin inhibitors
ASA NSAIDS Opoids Metaclopramide

Treatment of acute attack of migraine

II.

Specific serotonin agonist

Triptens selective [ 5 HT1 B/D agonist ]
Rizatriptan [ Narameg 2.5 mg ] Eletriptan [ Relepax 40 , 80 mg ] Zolmitriptan [ zomig 2.5 , 5 mg ] Naratriptan [ Maxalt 10 mg ] Sumatriptan [ Imigran 5mg, amp 6mg,]

Non selective
Ergotamine dihydroergotamine [ nasal spray , amp. ]

Migraine prevention

Beta blockers Tricyclic antidepressants SSRIs & SNRIs AEDS; Valproate, topiramate Calcium channel blockers
Verapmil,

Flunarizine pizotifin

5-HT2 antagonists
Cyproheptadine,

Botulinum toxins

Chronic daily headache

Chronic migraine or transformed migraine [ mixed type , medication overuse ]

Chronic tension-type headache New persistent daily headache

Hemicrania continua [ episodic , chronic ]

TREATMENT
1- stop drug abrupt or gradual 2- replacement with NSAIDs DHE STEROIDS TRIPTANS METACLOPRAMIDE CHLORPROMAZINE TCAs Ms RELAXANTS 3- relaxation techniques , biofeedback & reassurance 4- Botulinum toxin A