heache ppt.pptx
- 1. Headache presentation by Dr Yasam Jeji Maheswara Sai 1st yr Post Graduate MD General Medicine Moderator Dr T Mouleswara kumar Associate Professor General Medicine MIMS Dr P.CH. Mishra Proff & HOD Department of General Medicine MIMS
- 2. Definition : pain or discomfort in the head or upper neck region, the pain originates from tissues and structures that surround brain or skull International headache society Primary Headche – headache features are disorder itself which often results in considerable disability and ↓QUALY Secondary Headache -- exogenous disorders which are mostly by URTI and are rarely . worrisome
- 5. Origin Stimulated nociceptors due to Tissue injury visceral distension other factors damage pain producing pathway central peripheral
- 6. Pain sensitive structures scalp meningeal arteries dural sinuses flax cerebri proximal segments of large pial arteries Pain insensitive structures Ventricular ependyma choroid plexus plial veins brain parenchyma
- 7. Primary Headache Involves - Trigemino vascular complex Large intracranial vessels dural mater peripheral nerves of trigeminal nerve Pathway 5th CN + C1 C2 nerve roots --trigeminocervical complex Dorsal horns of upper cervical spinal cord caudal portion of trigeminal nerve ventroposteromedial thalamus cortex
- 8. Modulation from trigeminal nociceptors at all levels of pain pathway via Hypothalamus and brainstem structures Trigeminal autonomic cephalalgias ( TACs ) symptoms lacrimation conjunctival injection Nasal congestion rhinorrhea periorbital swelling aural fullness ptosis
- 9. Primary headaches are not vascular headaches Migraine and other primary headaches Do not manifest vascular changes Treatment outcomes cannot be predicted by vascular effects
- 10. Approach to New Onset Headache In New onset headache probability of potential serious cause is greater than than reccurent headaches when red flag signs are present History and examination cranial arteries palpation passive cervical spine movement cvs and renal status BP monitoring ,CUE fundoscopy , IOP management , refraction Checklist of red flags MRI / CT LP if advised by physician Psycological consulation at last to r/o depression and anxiety as their relation exits with headpain
- 11. Clues to identify secondary ICH --- SAH acute < 5 min severe > 5 min stiff neck but no fever ----ruptured aneurysm , Av malf ,intraparenchymal H”Ge high BP in majority cases present with headache alone ---- CT can miss small H’Ge below foramen magnum
- 12. Meningitis stiff neck with fever acute , severe Headache accentuation of pain with eye movement MISTAKEN FOR MIGRAINE LP is mandatory Brain tumor --- 30% patients presents with chief complaint of headache intermittent deep dull aching moderate intensity worsen with exertion / positional change asso with nausea & vomiting sleep disturbances vomiting precedes Headache
- 13. Amenorrhea/ Galactorea prolactin secreting pituitary adenoma Malignancy – cerebral metastasis ca meningitis or both Pain after bending , lifting or coughing post fossa mass chiari malformation low CSF volume
- 14. Glaucoma - HA start with severe eye pain asso with nausea & vomiting eye is often red with fixed dilated pupil Gaint cell arteritis – elderly female pain increases gradually over few hours before the peak . . . intensity is reached explosive occasionally dull and boring type polymyalgia rheumatica jaw claudicaton fever , weight loss scalp tenderness difficulty to comb or rest over the pillow red tender nodules , streaky red skin 50 % develop blindness high ESR / CRP but not always
- 16. Medication – overuse Headache Medication overuse Can aggravate headache frequency Markedly impair the effect of preventive medicines State of refractory daily or near daily headache On stopping analgesics substantial improvement in the severity and frequency especially with opioids or barbiturates
- 17. OPD management Analgesic to be reduced & eliminated reduce dose by 10% every 1-2 weeks Rescue for residual effect a small dose NASIDS is not a problem for patients Once patient has reduced the analgesic use substantially preventive medication is to be introduced
- 18. IPD management Day 1 Acute medication are withdrawn hydration and antiemetics are to be administered as required . Clonidine for opiod withdrawl symptoms If pain is intolerable aspirin 1g IV , chlorpromazine IM at night Day 3-5 withdrawl symptoms disappear IV ( DHE ) dihydroerogotamie TID _ 5 days induces significant remission that allows a preventive medicine to be established
- 19. Primary chronic daily Headache MCA (monoclonal antibody) to CGRP or its receptor effective in chr Migraine in phase II/ III RCT over placebo Non invasive neuro modulatory approaches single pulse transcranial magnetic stimulation Non invasive vagal nerve stimulation modulate thalamic processing / brainstem mechanism respectively chronic cluster headache chronic paroxysomal hemicrania SUNA & SCUNT
- 20. NEW DAILY PERSISTANT HEADACHE Headache in all days Onset begins abruptly patient can clearly recall the moment of onset Evolves over 3 days – to the max upper limit possible priority is to distinguish primary / secondary cause
- 22. Low CSF volume Headache Onset : headache from day 1 to the next day generally not present on waking but worsens during the day Positional begins when pt sits or stands upright resolves on reclining Site and character occipitofrontol dull ache but may be throbbing
- 23. Etiology of low CSF vol headache CSF leak following LP ( most common ) 10-30 % incidence begins in 48hrs can be delayed upto 12 days temporary relief with caffeine beverages epidural injection vigorous valsalva such as lifting , straining , coughing , clearing ET in airplane DD – postural orthostatic tachycardia syndrome
- 24. Mechanism : low volume rather low pressure IOC : MRI with gadolinium – shows diffuse meningeal enhancement MRI spine with T2 weighting – reveals leak Source of leak spinal MRI with appropriate sequences CT MR myelography 111 In-DTPA csf study
- 25. Management bed rest initially if pain is persistant ‘ IV caffeine 500mg in 500ml NS @ 2hr ECG to screen arrhythmia before administering if needed caffeine can be given twice before going for additional test If unsuccessful ---- abdominal binder If interactable ---- oral theophylline If leak identified --- autologous blood patch
- 26. Headache of raised ICT Generalise headache present on waking up improves as the day goes on worsen with recumbency Visual obscurations are frequent Dx straightforward if papilledema possible even in pt without fundoscopic changes frontal visual field testing helps DD ---uncontrolled HTN , OSA
- 27. Investigation MRI with MR Venogram CSF pressure on removal of 20-30 ml Management : Acetazolamide 250-500 mg BD ---improves in weeks if ineffective : Topiramate CA inhibitor , weight loss neuronal membrane stabilization if still refractory : ICP monitoring and may require shunting
- 28. Post traumatic headache Injury / Infection/ surgery / SAH can trigger headache last for month or year after the event with dizziness , vertigo , impaired memory May remit after several weeks / months / years after injury CNS examination is normal CT /MRI are unreavealing Mimc --- SDH
- 31. Migraine Most common headache related and indeed neurologic cause of disability in the world 2nd most common cause of headache
- 32. Pathogenesis of migraine sensory sensitivity that is characteristic of migraine is probably due to dysfunction of monoaminergic sensory control systems located in the brainstem and hypothalamus Activation of cells in the trigeminal nucleus results in the release of calcitonin gene–related peptide (CGRP), at vascular terminals of the trigeminal nerve and within the trigeminal nucleus. the involvement of the neurotransmitter 5-hydroxytryptamine (5-HT; also known as serotonin)is seen
- 33. Brainstem pathway that modulate sensory input Trigeminovascular input from meningeal vessels passes through trigeminal ganglion , synapses on 2nd order neuron in TCC these neurons project into quintothalamic tract after decussating in brainstem , synapses with neurons in thalamus Important modulation of Trigeniovascular nociceptive input comes from dorsal raphe nucleus , locus ceruleus and nucleus raphae magnus
- 35. Migraine genetics Familial hemiplegic migraine(FHM) FHM 1 ___: cav2.1 (P/Q) type voltage gated ca channel CACNA1A FHM2 ---- Na K ATPase gene FHM3 ___neuronal voltage gated Na channel SCN1A Functional neuroimaging : brain stem involvement in migraine posterior hypothalamic gray matter region suprachiasmatic nucleus in . cluster headache
- 40. Non pharmacological treatment Avoid trigger _ when pt can identify triggers A regulated lifestyle healthy diet , regular exercise regular sleep patterns avoid excess caffine / alcohol avoid stress Practical tip : lower the avoidable stress by Yoga, meditation , hypnosis conditioning techniques such as biofeedback
- 48. Cluster headache
- 49. Acute attack of cluster headache Mostly nocturnal ,unilateral , periodicity O2 inhalation 10-12 L/min for 15-20 min sumatriptan 6mg s/c rapid onset shorten attack to 10-15 min Suminat 20 & zolmitriptan 5mg nasal sprays nVNS 2min stimulation cycles applied consequetively at the onset of .headache on side of pain can be repeated after 9min Preventive measures : limited use of glucocorticoids greater occipital nerve injection with glucocorticoids , lidocaine
- 51. Primary paroxysmal hemicrania M: F – 1:1 Site tends to be retroorbital ,can be seen all over the head Features : unilareral very severe pain short lasting attacks 2-45 min very frequent attacks >5 /day marked autonomic features ipsilateral to pain are seen rapid course < 72hrs excellent response to indomethacin nVNS can be useful
- 52. Secondary paroxysmal hemicrania Lesions in sella turcica Av malformation cavernous sinus meningioma pituitary pathology epidermoid tumors More likely in pt requiring high doses of indomethacin > 200mg/day MRI is indicated to R/o pituitary lesion
- 53. SUNCT/SUNA SUNT : severe U/L orbital /temporal pain stabbing / throbbing quality diagnosis : require 20 attacks lasting for 5-240 sec ipsilateral conjunctival injection & lacrimation Suspect SUNCT – cutaneous triggers without refractory periods between attacks . . lack of response to indomethacin Secondary SUNCT – can be seen in posterior fossa / pituitary lesions r/o by pituitary function test & MRI brain with pituitary views
- 54. Treatment : IV lidocaine which arrest symptoms can be used in hospitalised pt Prevention : lamotrigine 200-400 mg/dl topiramate & gabapentin can also be used occipital nerve stimulation
- 56. Hemicrania continua Onset 10-70 yrs women twice affected than men moderate and continuous U/L associated with severe pain ass with autonomic feautures conjunctival injection , lacrimation , photophobia on affected side Treatment : inj indomethacin 100mg IM is diagnostic tool oral dose of 25mg f/b 50mg /75mg TID can be given occipital nerve stimulation in pt unable to tolerate indomethacin
- 57. Primary cough headache Generalized headache due to cough begins shuddenly last for seconds / several minutes upto few hours R/O secondary causes Arnold chairi malformation any lesion obstructing CSF pathways cerebral aneurysm , carotid stenosis vertebrobasilar disease Treatment : indomethacin 25-50 mg BD /TID some may require LP
- 58. Primary exercise headache Pulsatile quality of migraine headache last < 48hr B/l often throbbing migraine feautures may be seen Secondary cause : cardiac cephalgis - anginal pain refered to head probably by central connections of vagal afferents may present as exercise headache Treatment : Indomethacin at daily doses from 25–150 mg is generally effective. prevention : Indomethacin (50 mg), a gepant , ergotamine (1 mg orally), and dihydroergotamine (2 mg by nasal spray) are used.
- 59. Headache with sexual activity Mostly in men 3 types 1 b/l in head & neck intensifies on excitement 2 shudden severe explosion occuring at orgasm 3 postural headache after coitus Secondary causes like SAH in 5-12% Treatment : propranolol 40-200mg/day CCB _ diltiazem 60mg TID Indomethacin 25-50 mg 30-45 min before activity is helpful
- 60. Primary thunderclap headache Reversible cerebral segmental vasoconstriction resolves spontaneously by 12 weeks Treatment : Nimodipine is useful DD: sentinel bleed of IC aneurysm cervico cephalic arterial dissection cerebral venous thrombosis pheochromocytoma pt on MAOIs taking sympatomimitic drug / thiamine containing food cheese reaction
- 61. Cold stimulus headache Ingestion / inhalation of cold substance resolves in 10-30 min of stimulus withdrawl TRPM 8 –transient receptor potential cation subfamily M member 8 cold temperature sensor this mediate this syndrome
- 62. External pressure headache Headache stimulus Due to external pressure like helmets, swimming goggles or very long ponytails Treatment : recognise and remove the problem
- 63. Primary stabbing headache Ice pick pains / jabs & jolts Last for 1 to many seconds occurs as a single stab or series of stabs Absent cranial autonomic feature cutaneous triggering Reccurent type at irregular interval (hours to days) Treatment : indomethacine 25-50 mg BD/ TID is excellent
- 64. Nummular headache Continuous/ intermittent type in a fixed place of 1-6 cm size elliptical discomfort associated with allodynia / hypesthesia Treatment : tricyclics like amitriptyline anticonvulsants like topiramate / valproate
- 65. Hypnic headache After 6o years age mostly female Begins few hrs after sleep 2 * Due to poor control of HTN so 24hr BP monitoring is required Headache for 15-30 min can be throbbing unilateral ..upto 3 times/night Migraine features are not seen Treatment lithium carbonate 200-600 mg HS or verapamil 160mg Hs 1 / 2 cups coffe or 6omg caffeine po is effective others like flunarizine 5mg HS / indomethacine 25-75 mg HS
- 66. References Harrison principles of medicine 22nd edition International headache society guideliness 2018
- 67. Thank you…