Fifth Stage
Internal Medicine
Dr. Abbas / Lec . 3
1
HEADACHES AND OTHER HEAD PAIN
Headache is a very common complaint encountered by practitioners in almost
every specialty of medicine and surgery. More than 90% of the population experience
headache of one type or another at least once during life.
Classifications of headache
Primary headaches
Are those in which headache and its associated features are the disorder in itself,
Primary headache often results in considerable disability and a decrease in the patient's
quality of life.
Secondary headaches
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Are those caused by exogenous disorders.
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Mild secondary headache, such as that seen in association with upper respiratory
tract infections, is common but rarely worrisome. Life-threatening headache is
relatively uncommon, but vigilance is required in order to recognize and
appropriately treat patients with this category of head pain.
Mechanism
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Pain receptors are located at the base of the brain in arteries and veins and
throughout meninges, extra cranial vessels, scalp, neck and facial muscles, Para
nasal sinuses, eyes and teeth.
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Curiously, brain substance is almost devoid of pain receptors ..
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Head pain is mediated by mechanical (e.g. stretching of meninges) and chemical
receptors (e.g. 5-hydroxytryptamine and histamine stimulation). Nerve impulses
travel centrally via fifth and ninth cranial nerves and via upper cervical sensory
roots accompaniment.
2
Pressure headaches
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HEADACHE OF RAISED INTRACRANIAL PRESSURE
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Worse in morning, improves through the day
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Associated with morning vomiting
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Worse bending forward
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Worse with cough and straining
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Relieved by analgesia
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Dull ache, often mild
A single episode of severe headache:
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Serious causes to be considered include meningitis, subarachnoid hemorrhage,
epidural or subdural hematoma, glaucoma, and purulent sinusitis.
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Particular attention should be paid to suddenness of onset (suggestive of
subarachnoid hemorrhage), neck stiffness and vomiting (meningeal irritation), and
to the presence of a rash and/or fever (bacterial meningitisز
Factors that should increase suspicion of an intracranial tumor
include:
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papilledema,
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new neurologic deficits,
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initial attack of prolonged headache occurring after the age of 45 years,
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previous malignancy, cognitive abnormality,
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and altered mental status.
3
Idiopathic Intracranial Hypertension (IIH):
This syndrome, also called benign intracranial hypertension, is defined as a syndrome
of elevated intracranial pressure without evidence of focal lesions, hydrocephalus, or
frank brain edema. It occurs usually between the ages of 15 and 45 and is more
frequent in obese women. The disorder is characterized by headache. At times, patients
have visual disturbances, such as restricted peripheral visual fields, enlarged blind
spots, slight visual blurring, or diplopia secondary to abducents nerve palsies.
Funduscopic examination shows papilledema, which is often more impressive than
the clinical picture. IIH is usually a benign and self-limited disorder, but it may lead to
visual loss, including blindness. The headache is usually insidious in onset, is typically
generalized, is relatively mild in severity, and is often worse in the morning or after
exertion (e.g., straining or coughing
The condition has been associated with drugs-vitamin A intoxication, nalidixic acid,
danazol (Danocrine), and isotretinoin (Accutane)-as well as corticosteroid withdrawal
and with systemic disorders such as hypoparathyroidism and lupus.
CT is usually normal but can show small ventricles and an "empty sella" in some
cases. CSF opening pressure is elevated, usually in the range of 250 to 450 mm of
water, with the pressure fluctuating markedly when monitored over a prolonged period .
Treatment:
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After eliminating secondary causes of IIH, the patient should have dietary
counseling for weight loss. Carbonic anhydrase inhibitors (acetazolamide) and
corticosteroids have proved useful in headache control. As a second-line agent,
furosemide also acts to lower CSF production. Serial lumbar punctures are
understandably unpopular with patients even though transient headache relief is
obtained. CSF shunting procedures (ventriculoperitoneal shunt) are occasionally
necessary
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For patients with progressive visual loss, optic nerve sheath fenestration has been
shown to preserve or restore vision in 80 to 90% and provide headache relief in a
majority. Intracranial hypotension (usually secondary to a CSF leak after
trauma or lumbar puncture) may also cause headache, exacerbated by
standing .
4
'Tension' headache:
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The vast majority of chronic and recurrent headaches are believed to be produced
by 'neurovascular irritation' and tension within scalp muscles. Despite universal
occurrence, precise mechanisms of common headache remain obscure. Tight
band sensations, pressure behind the eyes, throbbing and bursting sensations are
common. What is clear is that almost all headaches with these features are
benign
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There may be obvious precipitating factors such as worry, noise, concentrated
visual effort or fumes. Depression is also a frequent underlying feature. Tension
headaches are often attributed to cervical spondylosis, refractive errors or high
blood pressure. Evidence for such associations is poor. Headaches also follow
even minor head injuries. Tenderness/tension in neck and scalp muscles are the
only physical signs
Management:
This involves :
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firm reassurance (imaging is often needed(
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avoiding evident causes, e.g. bright lights
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analgesic withdrawal
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physical treatments - massage, icepacks, relaxation
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antidepressants - when indicated
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drugs for recurrent headache/migraine .
Thank you,,,