HEADACHE
Pain Sensitive StructuresIntracranial:
1-Blood vessels:v. sinuses; meningeal, cerebral and internal carotid arteries.
2-Dura at the base of the skull.
3-Cranial somatic nerves (v, ix, x).
4-Brain stem periaqueduct ,grey matter.
5-Sensory thalamic nuclei.
Extra cranial:
1-Periosteum.
2-Skin ,subcutaneous tissue ,muscles and arteries.
3-Second and third cervical roots.
4-Eyes ,ears ,teeth ,sinuses ,nasal mucosa.
Mechanism Of Headache
1-Displacement : S.O.L., raised intracranial pressure, decrease CSF pressure.
2-Irritation : of meningeal nerves and vessels ;e.g. meningitis and SAH; somatic cranial nerves.
3-Vascular : throbbing through afferent nerve fibers to thalamus then to cortex.
4-Muscle spasm.
Approach To Patient with Headache
1-Onset:Acute,subacute,chronic headache
2-Precipitating factors: food, tension or emotional stress, menses, drugs, position, systemic or local illness …
3-Prodromal symptoms or aura
4-Characteristics of pain: throbbing, dull and steady, tightness or pressure, sharp Lancinating pain
5-Location:unilat. Ocular, paranasal, focal Occipital, frontal, bandlike…
6-Associated symptoms: fever,wt. loss, visual disturbances, nausea and vomiting, photophobia, rhinorrhea, lacremiation loss of consciousness
7-Timing and pattern : morning, on awakening, During sleep, episodic max.at evening, clustering
8-Relieving factors: sleep, vomiting, pressure Position, darkness…
9-Exacerbating factors: change in head position coughing ,sneezing, anger…
10-History and frequency of the headache.
Classification
Part 1:Primary headache disorders
Part 2: Secondary headache disorders
Part 3: Cranial neuralgias, central and primary facial pain and other headaches
Primary or secondary headache?
Primary:
no other causative disorder
Secondary (ie, caused by another disorder):
new headache occurring in close temporal relation to another disorder that is a known cause of headache
Classification
Part 1: The primary headaches
1. Migraine
2. Tension-type headache
3. Cluster headache and other trigeminal autonomic cephalalgias
4. Other primary headaches
Part 2: The secondary headaches
1. Headache attributed to head and/or neck trauma.
2.Headache attributed to cranial or cervical vascular disorder.
3. Headache attributed to non-vascular intracranial disorder.
4. Headache attributed to a substance or its withdrawal.
5.Headache attributed to infection.
6.Headache attributed to disorder of hamoeostasis
7. Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures
8.Headache attributed to psychiatric disorder
Part 3: Cranial neuralgias, central and primary facial pain and other headaches
1. Cranial neuralgias and central causes of facial pain
2. Other headache, central or primary facial pain
‘Chronic’Notes
In pain terminology, chronic denotes persistence over a period of more than 3 months
In headache terminology, it retains this meaning for secondary headache disorders
For primary headache disorders that are more usually episodic (eg, migraine), chronic is used whenever headache occurs on more days than not (>15 days)over more than 3 months
the trigeminal autonomic cephalalgias (qv) are an exception
MIGRAINE
Definition: It is an episodic paroxysmal
headache usually unilateral and frequently pulsatile in quality. It is often associated with nausea, vomiting, photophobia, phonophobia and lassitude. Visual or other neurological auras occur in about 10% of patients.
Migraine occurs in: ( prevalence)
4% of children.
6% of male.
18% of females.
Two third to three fourth of cases occur in women.
Onset: is early in live;
25% begin in first decade
55% by 20 years of age
>90% before age of 40
Family history of migraine is present in most cases.
Clinical types of Migraine
1. Migraine without aura (common migraine)
A. At least 5 attacks fulfilling criteria B-D
B. Headache attacks lasting 4-72 h (untreated or unsuccessfully treated)
C. Headache has 2 of the following characteristics:
1. unilateral location
2. pulsating quality
3. moderate or severe pain intensity
4. aggravation by or causing avoidance of routine physical activity (eg, walking, climbing stairs)
D. During headache 1 of the following:
1. nausea and/or vomiting
2. photophobia and phonophobia
E. Not attributed to another disorder
2- Migraine with aura (classical migraine):(at least 2 attacks)
The headache preceded by transient neurological symptoms, , lasting from 5-60 min. most common auras are visual alteration; hemianopic field defects and scotomas; sensory symptoms; no motor weakness.
3-Basilar type migraine.
4-Migraine equivalent; typical aura without headache.
5-Hemiplegic migraine: familial or sporadic.
6-Abdominal migraine.
Precipitating Factors:
Certain foods(tyramine-containing cheese; meat with nitrite preservatives; banana;
Chocolate containing phenyl ethylamine), drugs, stress, menses.
By : younis alomary