Headache

Headaches are a type of pain referred to the

surface of the head from deep head structures. Some headaches result from pain stimuli arising inside the cranium. Others result from pain arising outside the cranium, such as from paranasal sinuses. About 45% of adults report that at some time, they have experienced a severe or disabling headache
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Basic mechanisms of headache

Increased intracranial pressure from tumor or

hemorrhage -- Can stretch or distort blood vessels --Can compress or irritate cranial or cervical nerves Vascular distention and dilation, especially arteries --Occurs in response to neurotransmitters released in migraine

Basic mechanisms of headache

Inflammation of the mucosal structures, paranasal

sinuses, meninges, or perivascular areas. Possibly sustained contraction of skeletal muscles of neck and scalp. Incidence of headache in the males and females Typically 70% of migraine occur in females and 30% in males. Cluster headaches occur almost entirely in men(90%)

Basic mechanisms of headache

Headache pain can be generated by skin, blood

vessels, and muscles of the scalp, face, and neck; by large intracranial blood vessels; and by sensory afferents from the head and neck.
The brain parenchyma itself does not produce

pain. Pain-sensitive cranial structures1.Scalp 2. Scalp blood supply 3. Head and neck muscles 4. Great venous sinuses 5. Arteries of the meninges 6. Large cerebral arteries 7. Pain-sensitive fibers of the 5th, 9th, and 10th cranial nerves 8. Parts of duramater at the base of the brain
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Basic mechanisms of headache

Tugging on the venous sinuses around the brain,

damaging the tentorium, or stretching the dura at the base of the brain can cause intense pain that is recognized as headache. Any type of traumatizing, crushing, or stretching stimulus to the blood vessels of the meninges can cause headache.

Headache as a sign of a serious neurologic problem

Some indications that a headache

may be due to a serious underlying illness include: 1. Sudden onset of severe headache 2. Headache accompanied by impaired mental status, severe, seizure, or focal neurologic signs 3. New headache beginning after age 50.
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Common, serious diseases may present as a headache

Primary brain Meningitis

tumor Metastatic brain tumor Brain abscess Subdural hematoma Intracerebral hemorrhage Subarachnoid

Temporal arteritis
Hypertension Hydrocephalus Glaucoma

Areas of the Head to Which Intracranial Headache is Referred

Stimulation of pain receptors in the cerebral vault

above the tentorium cerebelli---headache pain is felt to the front half of the head---the area innervated by the trigeminal nerve. Subtentorial pain stimuli cause occipital headache referred to posterior part of the head.

Types of Intracranial Headache

1. Headache of Meningitis

2. Headache Caused by Low Cerebrospinal

Pressure 3. Migraine Headache 4. Alcoholic Headache 5. Headache Caused by Constipation

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Extracranial Types of Headache

1. Headache Resulting from Muscle Spasm

2. Headache Caused by Irritation of Nasal and

Accessory Nasal Structures 3. Headache Caused by Eye Disorders

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Headache of Meningitis
One of the most severe headache of all is that

resulting from inflammation of all the meninges including the sensitive areas of the dura and the sensitive areas around the venous sinuses It can cause extreme headache pain referred over the entire head.

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Symptoms of Meningitis in Adults

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Headache Caused by Low Cerebrospinal Fluid Pressure

This happens following lumbar puncture and

removing as little as 20 milliliters of fluid from the spinal canal, particularly if the person remains in an upright position, often causes intense intracranial headache. This is due to stress and distortion of the dural surfaces.

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Migraine with aura (classical migraine)

Signs and symptoms Prodrome of flashing or scintillating lights in all

part of a visual field because of disturbance in the occipital cortex. Patches of visual loss may accompany scintillations Severe, incapaciating, throbbing, pounding, unilateral headaches Poor tolerance of light (photophobia)or sound(phonophobia) Often autonomic symptoms of sweating, nausea, vomiting, dizziness

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Migraine with aura (classical migraine)

Headache and malaise can last 1 to 2 days

Frequent family history of migraine

More common in women

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Migraine headache

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Migraine without aura (common migraine)

No visual prodrome, but possibly vague illness

before onset of headaches Otherwise similar to migraine with aura More common in women

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Cluster headache
Severe headaches of

shorter duration(15 minutes to 3 hours) occurring in cluster of days or weeks, followed by long periods of remission

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Cluster headache (signs and symptoms)

--- Periorbital pain

---Ipsilateral red, watery eye

---Occasional transient Horners syndrome ---Nasal discharge and congestion More common in man

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(hemiplegic, ophthalmoplegic, basilar types)

Signs and symptoms before or after migrainous

headache --Hemiplegia --Extraocular muscle palsy --Other brain symptoms Rarely leads to ischemic infraction with permanent deficit

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Mechanisms of migraine
1. Vascular reactivity Vasoconstriction of occipital arteries can cause a

visual prodrome. Vasodilation of extracranial arteries can cause a throbbing headache in susceptible subjects. Vasoactive drugs can worsen (e.g., nitroglycerine) or relieve(e.g.,ergotamin) migraine The initial trigger of this vascular response is uncertain.

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Mechanisms of migraine
2. Trigeminovascular theory

Vasodilation of extracranial(scalp, dural)

arteries leads to pain perception, nausea or vomiting, and photophobia via perivascular trigeminal afferents to brain stem and hypothalamus. The trigeminal afferents can also antidromically (in reverse direction) release substance P (pain neurotransmitter) at vascular sites, causing neurogenic inflammation.
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Mechanisms of migraine
Trigeminovascular theory Serotonergic (raphe nuclei) or even

noradrenergic (locus ceruleus) neurons could directly or indirectly initiate this abnormal vasodilation, perhaps maintained by trigeminovascular pathway. ---Serotonin is present in brain, blood vessels, gastrointestinal tract, and platelets---all of which react abnormally ---Many drugs helpful in migraine affect serotonin receptors.

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Factors precipitating migraine headache

Light Noise Stress and being overweight Certain foods like chocolates, cheese, and food

additive like MSG found in Chinese food Menstruation Smoking and drinking alcohol

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Factors precipitating migraine headache

The predominance of certain triggers for migraine was

assessed in 494 migraine patients. Stress (62%) was the most frequently cited precipitant. Weather changes (43%), missing a meal (40%), and bright sunlight (38%) were also prominent factors. Sexual activity (5%) was the precipitant cited by the least number of patients. Significant differences were found between men and women in their responses to weather changes, perfumes, cigarette smoke, missing a meal, and sexual activity. Spring was cited by 14% of patients as a time for increased migraine attacks, followed by fall (13%), summer (11%), and winter (7%)
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Treatment of migraine
Stress management, relaxation

Avoidance of dietary precipitants

Nonspecific drugs (analgesic, sedatives, anti-

inflammatory) with possible risk of dependence or addiction Specific drugs to abort and attack ---Ergot alkaloids, including dihydroergotamine(DHE) ---Sumatriptan, other triptans like naratriptan

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Treatment of migraine
Specific drug to prevent an attack

adrenergic blockers (e.g.,propranolol)

Calcium channel blockers (Verapamil) Methysergide Tricyclic antidepressant Valproate

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Acknowledgement
The images in the presentation have been taken

from multiple resources for teaching purpose only. Dr. Dewan S Raja M.D.,M.Phil.

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