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Headache

Headache. Dr sadik al ghazawi Associated professer Neurologist Mrcp,frcp uk. Accounts for 1 % to 2% of emergency department evaluations and up to 4% of medical office visits

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Headache

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  1. Headache Dr sadik al ghazawi Associated professer Neurologist Mrcp,frcpuk

  2. Accounts for 1% to 2% of emergency department evaluations and up to 4% of medical office visits • Headache is caused by traction, displacement, inflammation, or distention of the pain-sensitive structures in the head or neck

  3. Intracranial Pain-Sensitive Structures • Venous sinuses • Anterior and middle meningeal arteries • Dura at the base of the skull • Trigeminal (V), glossopharyngeal (IX), and vagus (X) nerves • Proximal portions of the internal carotid artery and its branches near the circle of Willis • Brainstem periaqueductal gray matter • Sensory nuclei of the thalamus

  4. Venous sinuses

  5. periaqueductal gray matter

  6. Causes of headache • Secondary • Medication overuse (rebound) • head/neck trauma • Vascular disorder – SAH, AVM, vasculitis,High ICP / Low ICP • Tumor • Infection • CNS • Other infections • Primary • Migraine • Tension-type • Cluster • Paroxysmal hemicrania • Trigeminal neuralgia • Chronic daily headache

  7. Red Flags in Hx • “Worst HA of my life” • New onset HA • Change in character of headache • Awakens him from sleep • Associated with focal symptomsor fever • Worsening with bending, laying down, coughing or sneezing • Immunocompromised • h/o cancer

  8. Migraine • Prevalence 12% • More than 90% before age 40 • begins with visual or other neurologic symptoms in approximately 15% to 20% of patients (migraine with aura, or classic migraine) • In most cases no aura occurs (migraine without aura, or common migraine

  9. Diagnostic Criteria: • A. At least 5 attacks fulfilling criteria B through D • B. Headache attacks lasting 4 to 72 hours (untreated or unsuccessfully treated) • C. Headache has at least two of the following characteristics: • Unilateral location • Pulsating quality • Moderate or severe pain intensity • Aggravation by or causing avoidance of routine physical activity (eg, walking or climbing stairs)

  10. D. During headache at least one of the following: • 1. Nausea and/or vomiting • 2. Photophobia and phonophobia • E. Not attributed to another disorder

  11. Management • Prophylactic B Blocker prpronalol Topamax Antidepressant ( amytriptyline) • Abortive Analgesia brufine Sumatriptan Ergot (cafergot ,

  12. Tension headache • A. At least 10 episodes • Fulfilling criteria B through D listed below • B. Headache lasting from 30 minutes to 7 days • C. Headache has at least two of the following pain characteristics: • 1. Bilateral location • 2. Mild or moderate intensity (may inhibit but does not prohibit activity) • 3. Pressing/tightening (non-pulsating) quality • 4. No aggravation while climbing stairs or similar routine physical activity

  13. D. Both of the following: 1. No nausea or vomiting (anorexia may still occur)2. No more than one of photophobia and phonophobia E. Not attributed to another disorder

  14. Cluster HA • A. At least five attacks fulfilling criteria B through D • B. Severe or very severe unilateral orbital, supraorbital, and/or temporal pain lasting 15 to 180 minutes if untreated • C. Headache is accompanied by at least one of the following: • 1. Ipsilateral conjunctival injection and/or lacrimation • 2. Ipsilateral nasal congestion and/or rhinorrhea • 3. Ipsilateral eyelid edema • 4. Ipsilateral forehead and facial sweating • 5. Ipsilateral miosis and/or ptosis • 6. A sense of restlessness or agitation

  15. D. Attacks have a frequency from one every other day to eight per day. E. Not attributed to another disorder

  16. Trigeminal neuralgia (tic douloureux) 1-In many instances, the trigeminal (V) nerve roots are close to a vascular structure, and microvascularcompression followed by demyelination of the nerve is believed to cause the disorder. 2-Second (V2) and third (V3) divisions of the trigeminal (V) nerve

  17. 3-Lightning-like momentary (>1 second to approximately 2 minutes) • 4-Trigger zones about the cheek, nose, or mouth by touch, cold, wind, talking, or chewing can precipitate the pain. • 5-Young pts, bilateral symptoms or abnormal exam • r/o MS and brainstem tumors

  18. Medication-overuse HA • A. Headache > or = 15 d/monthB. Regular overuse for >3 months of > or = 1 acute/symptomatic treatment drugs: • 1. Ergotamine, triptans, opioids, or combination analgesic medications on > or = 10 d/month on a regular basis for >3 months • 2. Simple analgesics or any combination of ergotamine, triptans, or analgesics opioids on > or = 15 d/month on a regular basis for >3 months without overuse of any single class alone • C. Headache developed or markedly worsened during medication overuse

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