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Pathophysiology

Challenge 2010
propound

Lecture Notes

Lecture Title : Headache Prof name : Dr.Mostafa Shihebat Done by : Pharmacy students Corrected by : Dentistry students

Headache
Today's lecture about headache What's headache? Is a pain anywhere in the region of head and neck . -Epidemiology: -85% of the US population had significant headaches at least once. -3to5% of ED (emergency department) visits have as chief complaint headache. -50% accounts for tension headache while only 8% of headache has a potentially serious cause. -Only 1% of headache in ED have life threatening cause(usually subarachnoid hemorrhage). "Headache is a symptom that might be related to a serious situation" . ** it reflects that there is a problem and sometimes it reflect a serious problem ex: subarachnoid hemorrhage which is fatal even it occurs in only 1% . -So we must be able to differentiate between different type of headache and how to deal with it.

*Rapid Assessment and Stabilization : 1-If a patient come to the ED and he is complaining of headache , even he is complaining of any thing -What are the major things that we have to care for any patient?? -In general there are three things: 1-circulation: put IV line because in situation the patient become collaps 2-breathing maintenance: supply patient with oxygen 3-airway: keep patent air way "if there is a foreign body remove it

IV line: it is canula that we put in veins to give medication or IV fluid . ** *These 3 things for any patient conscious or subconscious You must to look for these 3 things (Any doctor able to deal with these 3 thing, is able to maintain the life of human being.

**There are other 2 things that we will talk about them in cvs. 2- If there is change in mental status accompanied by headache, it must be assumed that cerebral circulation is compromised. -So what types of headache are concerned?? -If headache is accompanied by change in alertness or consciousness this reflect that there is a proplem or something wrong in the brain, in the circulation so we have to take care about 3 things(airway,breathing,circulation )and to investigate the reason. *Pivot Findings in history : -Pattern and onset of pain -Activity at onset of pain -History of head trauma -History of HIV or immunocompromised state -Character of the pain -Location of head pain -Intensity of pain -Exacerbating or alleviating factors -Associated symptoms and risk factors -Prior history of headache **The history is important because it make a difference And by the way headache is a symptom of hundreds or thousands of disorder so we have to investigate . Headache is classified into: 1- Primary headaches: The most common types of headache it is

idiopathic such as : tension headache, migraine Rarer primary headache disorders are trigeminal neuralgia (a shooting face pain), cluster headache (severe pains that occur together in bouts), and hemicrania continua (a continuous headache on one side of the head). 2- Secondary headache: symptomatic it may secondary to either not harmfull or potentially dangerous causes Primary headaches are even more difficult to understand than secondary headaches. headache that worsens with changing posture, headache worsened by exertion or Valsalva manoeuvre (coughing, straining), visual loss or visual abnormalities, jaw claudication (jaw pain on chewing that resolves afterwards), neck stiffness, fever, and headaches in people with HIV, cancer or risk factors for thrombosis. "Wikipedia"

**Differential Diagnosis: -the most important differential diagnosis which are related to headache: 1-Subarachnoid hemorrhage: which reflect bleeding in subarachnoid (below arachnoid layer which is one of meningies layer(arachnoid,pia matter. Dura matter)) 2-Migrain 3-Tumor/Masses/ Subdural hematoma (hematoma :acuumlation of blood under skin or other area result from rupture of capillary)

Carbon Monoxide Poisoning(may lead to headaches as well as nausea, vomiting, dizziness, muscle weakness and blurred vision . wikipedia) 4- Mountain Sickness. 5-Temporal Arteritis. 6-Glaucoma/Sinusitis. 7-Tension headaches/ Cervical Sprain 8-Cluster. 9-Bacterial Meningitis/ Encephalitis(inflammation of the brain, usually due to particular viruses). 10-Anoxic Headache/ Anemia. 11 -Hypertensive crisis. **All these things are the most important things that are correlated to headache. -When we are talking about headache we talk about pain related to head and neck so what is the source of pain? **Brain tissue itself has no pain receptor

-Sources of headache pain: Veins, artery , nerves, muscles , subcutaneous tissue , eyes, nose, sinus(sinusitis is the common cause of headache)

*Migraine -Accounts for 1 million visits a year in the ED Onset is usually in second decade of life -More prevalent among women(while epilepsy in male more than female) (The cause of migraine headache is unknown the most supported theory is that it is related to hyperexcitability of the cerebral cortex and/or abnormal control of pain neurons in the trigeminal nucleus of the brainstem. Wikipedia) the important thing in Migraine : 1- It is severe headache 2- Attack lasts 4 to 72 hours with or without Treatment 3- Unilateral location (In one side) 4- Pulsating quality, and moderate to severe Intensity, aggravated or promoted by activity *Migraine with aura: -What is aura? * Public meaning : -The halo and is the magnetic field surrounding every human being *Aura in medicine? - Transient visual , sensory, language or motor disturbances signaling that migraine will soon occur **Means that patient complain of migraine can know the onset of occurrence this called aura of the brain it reflects visual symptoms or somatosensory

-Patients with migraine: " before few seconds or minutes the patient start seeing
something abnormal in his field or spots of light"

-Most common aura:( visual) a)scintillating scotomas: the most common visual aura that preceding migraine which is spots of light near or in the center of the visual field. b)photopsias: presence of perceived flashes of light. c)teichopsias: sensation of numerous appearance before the eye. d) blurred vision. Less common auras are somatosensory: a) tingling or numbness b) Motor disturbances c) cognitive disturbances *Drugs: -Dr. said: I am not interested I don't want you to know the drugs just you have to know the proper medication mostly analgesics "Unless there is underlying serious condition that we have to deal with as subarachnoid hemorrhage, meningitis, sinusitis, muscle stasis or whatever"

*Tension Headache: -Most common type of headache -Higher prevalence in middle aged women Usual frequency is 5 episodes per month (Tension-type headache pain is often described as a constant pressure, as if the head were being squeezed in a vise the pain is frequently bilateral)

*Clinical features include: -Tight, band-like discomfort around the head. - Intensity of pain is not severe and thus not debilitating. - Headache does not worsen with physical Activity. "In contrast to migraine" - Coexisting anxiety and depression are Common. *Brain tumor: is involved strongly in occurrence of headache People who have brain tumor have sever type of headache which not subsided by any type of analgesics. -In elderly, brain tumor is usually metastatic from lung or breast carcinoma. -Primary brain tumors are more common in adults younger than 50 years -headache is caused either by direct pressure on the brain or elevated ICP( intracranial pressure) -Typical presentation is headache that worsens over weeks to months -headache is usually present on awakening initially, then it becomes continuous

*Subarachnoid Hemorrhage headache (SAH): -Extravasations of blood in subarachnoid space activates meningeal nocireceptors (pain receptor) Causing occipital pain and meningismus. -SAH accounts for 10% of all strokes and is most Common cause of death from a stroke. -Stroke in general: either bleeding or thrombosis. -One student ask: What is the link between headache and subarachnoid hemorrhage? Dr. answer: subarachnoid hemorrhage it is bleeding in brain in subarachnoid below arachnoids layer that stimulate the pain receptor all over the area of hemorrhage leads to sever headache. -Clinical Features of SAH: It mostly causes : *Nausea / vomiting (75%). *Neck stiffness (25%) and seizures(10%). Other features: *Meningismus-50%. *Subhyloid or retinal hemorrhages. *Oculomotor nerve pulsy with dilated pupil. *Restlessness and altered level of consciousness.

*Diagnosis of headache : -We have to diagnose the underlying cause (tumor, hemorrhage, meningitis, sinusitis,or whatever) -The most common: x- ray other CT scan or MRI *When CT is negative a lumbar puncture should be performed **Sometimes we make tense and investigation and we dont found the cause of headache -Lumbar puncture: diagnostic procedure that used to collect cerebrospinal fluid (CSF) from lumbar area (located between fourth and fifth lumbar vertebra. It is diagnostic for many things related to the brain. **The CSF should be spun and the supernatant fluid should be observed for xanthochromia (Develops after 12 hrs) **Xanthochromia : yellowish discoloration of CSF Eg: in an accident and in the case of hemorrhage the CSF color become yellow

-Giant Cell Arteritis one of the most important sources of headache is blood vessels either arteries or veins one of these things Giant cell arteritis : is inflammation of blood vessels wall

**glaucoma: injury of optic nerve leads to sever headache. Dr.said: nothing more this what I want you to know in addition to the notice that I will give you The end

Q1: Who suffers more frequently from migraine headaches? a. Men over the age of 50 b. Women Q2: Which is the most common type of headaches? A. Tension headaches B. B. Migraine headaches C. C. Cluster headaches D. D. B & C only Q3: The trigeminal nerve is most closely associated with which type of headaches? A. Tension or stress headaches B. Cluster headaches Q4: Which is not a symptom of migraine headaches? A. Aura B. B. Fever C. C. Sensitivity to light D. D. Nausea and vomiting Q5: Sinus headaches are usually caused by: A. Inflammation of the sinuses B. Drainage of the sinuses

Q6: Tension headaches usually are so severe that they keep a person from performing daily tasks. A. True B. False Q7: Common migraine triggers include everything listed below, EXCEPT: A. Tobacco smoke, alcohol, and nitrites (food additives) B. Salt, allergies, milk, and aging C. MSG (monosodium glutamate), aspartame, and caffeine D. Chocolate, odors, and bright or flickering lights Q8: Migraine, sinus, tension, and cluster headaches are considered to belong to which category of headaches: A. Primary B. Secondary Q9: _____________ headaches generally strike at night. A. Migraine B. Cluster Q10: What is the trigeminal nerve? A. The fifth of 12 cranial nerves (nerves of the head) B. The main nerve of the face C. A nerve responsible for facial or cranial sensations such as pain D. All of the above

Q11: A migraine sufferer is also likely to suffer from: A. Tension or stress headaches B. Cluster headaches Q12: The "worst headache of your life" may be a symptom of a life-threatening infection known as: A. MRSA ( methicillin resistant staphylococcus aureus) B. Anaphylactic shock C. Migraine headache D. Meningitis Q13: Facial swelling is commonly associated with which type of headache: A. Migraine headache B. Cluster headache C. Tension headache E. Sinus Headache Q14: Common migraine headaches have been found to have a genetic basis. True False

Q15: With regard to headaches, the term "bilateral" best describes which type of pain: A. Pain that occurs with at least one additional symptom B. Pain that affects the top and the bottom of the head C. Pain that occurs on either side of the head D. Pain that affects both sides of the head Q16: of all headache types, which type of headache is recognized as the least common and most severe? A. Migraine headache B. Cluster headache C. Tension headache D. Sinus Headache _______________________________________________

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