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Fifth stage
Medicine
Lec-2
د.بشار
12/10/2015
Headache
Migraine
Migraine is an episodic primary headache disorder. Symptoms typically last 4 to 72 h and
may be severe. Pain is often unilateral, throbbing, worse with exertion, and accompanied
by symptoms such as nausea and sensitivity to light, sound, or odors. Auras occur in about
25% of patients, usually just before but sometimes after the headache
Epidemiology
Migraine is the most common cause of recurrent moderate to severe headache; 1-yr
prevalence is 18% for women and 6% for men in the US. Migraine most commonly begins
during puberty or young adulthood, waxing and waning in frequency and severity over the
ensuing years; it often diminishes after age 50. Studies show familial aggregation of
migraine
Pathophysiology
Migraine is thought to be a neurovascular pain syndrome with altered central neuronal
processing (activation of brain stem nuclei, cortical hyperexcitability, and spreading cortical
depression) and involvement of the trigeminovascular system (triggering neuropeptide
release, which causes painful inflammation in cranial vessels and the dura mater
Migraine triggers
Drinking red wine
Skipping meals
Excessive afferent stimuli (eg, flashing lights, strong odors)
Weather changes
Sleep deprivation
Stress
Hormonal factors
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Symptoms and Signs
Often, attacks are heralded by a prodrome (a sensation that a migraine is beginning), which
may include mood changes, loss of appetite, nausea, or a combination
An aura precedes attacks in about 25% of patients. Auras are temporary neurologic
disturbances that can affect sensation, balance, muscle coordination, speech, or vision;
they last minutes to an hour. The aura may persist after headache onset. Most commonly,
auras involve visual symptoms (fortification spectra—eg, binocular flashes, arcs of
scintillating lights, bright zigzags, scotomata
Headache varies from moderate to severe, and attacks last from 4 h to several days,
typically resolving with sleep. The pain is often unilateral but may be bilateral, most often in
a frontotemporal distribution, and is typically described as pulsating or throbbing
Other, rare forms of migraine can cause other symptoms. Basilar artery migraine causes
combinations of vertigo, ataxia, visual field loss, sensory disturbances, focal weakness, and
altered level of consciousness. Hemiplegic migraine, which may be sporadic or familial,
causes unilateral weakness
Diagnosis
Clinical evaluation
Diagnosis is based on characteristic symptoms and a normal physical examination, which
includes a thorough neurologic examination
Treatment
Elimination of triggers
For stress, behavioral interventions
For mild headaches, acetaminophen or NSAIDs
For severe attacks, triptans
Triptans are selective serotonin 1B,1D receptor agonists. They are not analgesic per se
but specifically block the release of vasoactive neuropeptides that trigger migraine pain.
Triptans are most effective when taken at the onset of attacks. They are available in
oral, intranasal, and sc forms.
When nausea is prominent, combining a triptan with an antiemetic at the onset of
attacks is effective.
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Prevention
Daily preventive therapy is warranted when frequent migraines interfere with activity
despite acute treatment.
Amitriptyline ,β-Blockers,Divalproex,
OnabotulinumtoxinA,Topiramate,Verapamil
Cluster Headache
Cluster headaches cause excruciating, unilateral periorbital or temporal pain, with
ipsilateral autonomic symptoms (ptosis, lacrimation, rhinorrhea, nasal congestion
Cluster headache affects primarily men, typically beginning at age 20 to 40; prevalence in
the US is 0.4%. Usually, cluster headache is episodic; for 1 to 3 mo, patients experience ≥ 1
attack/day, followed by remission for months to years
Pathophysiology is unknown, but the periodicity suggests hypothalamic dysfunction
Symptoms and Signs
Symptoms are distinctive. Attacks usually occur at the same time each day, often
awakening patients from sleep. Pain is always unilateral in an orbitotemporal distribution. It
is excruciating, peaking within minutes; it usually subsides spontaneously within 30 min to 1
h. Patients are agitated, restlessly pacing the floor, unlike migraine patients who prefer to
lie quietly in a darkened room
Autonomic features, including nasal congestion, rhinorrhea, lacrimation, facial flushing, and
Horner syndrome, are prominent and usually occur on the same side as the headache
Diagnosis
Diagnosis is based on the distinctive symptom pattern and exclusion of intracranial
abnormalities
Treatment
For aborting attacks, parenteral triptans, dihydroergotamine, or 100% O2
For long-term prophylaxis, verapamil, lithium, topiramate, divalproex, or a combination
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Tension-Type Headache
Tension-type headache causes mild generalized pain without the incapacity, nausea, or
photophobia associated with migraine
Tension-type headaches may be episodic or chronic. Episodic tension-type headaches occur
< 15 days/mo. Episodic tension-type headache is very common; most patients obtain relief
with OTC analgesics and do not seek medical attention. Tension-type headaches that occur
≥ 15 days/mo are considered chronic
Symptoms and Signs
The pain is usually mild to moderate and often described as viselike. These headaches
originate in the occipital or frontal region bilaterally and spread over the entire head.
Unlike migraine headaches, tension-type headaches are not accompanied by nausea and
vomiting and are not made worse by physical activity, light, sounds, or smells. Potential
triggers for chronic tension-type headache include sleep disturbances, stress,
temporomandibular joint dysfunction, neck pain, and eyestrain
Episodic headaches may last 30 min to several days. They typically start several hours after
waking and worsen as the day progresses. They rarely awaken patients from sleep
Diagnosis
Diagnosis is based on characteristic symptoms and a normal physical examination, which
includes a neurologic examination
Treatment
Analgesics
Sometimes behavioral and psychologic interventions