Headache ppt totally based on Davidson's principle and practice of Medicine, 22nd Edition

1. Headache
Dr. Mehedi Hasan
Dept. of Medicine
Central Medical College, Comilla.

2. Headache
 Headache is common and causes
considerable worry, but rarely represents
sinister disease

3.  The causes may be divided into primary
(benign) or secondary

4. Primary and secondary
headache syndromes

5. Red flag’ symptoms in
headache
 Sudden-onset headache, maximal
immediately, is always a ‘red flag’
 Should prompt rapid assessment in hospital
for possible subarachnoid hemorrhage or
other sinister causes

6. Red flag’ symptoms in headache

7. Primary headache syndromes
 Tension-type headache
 Migraine
 Medication overuse headache
 Cluster headache
 Headaches associated with specific activities
 Other headache syndromes

8. Tension-type headache
 Most common type of headache

9. Pathophysiology
 Incompletely understood
 Emotions and anxiety are common
precipitants
 Anxiety about the headache itself may lead to
continuation of symptoms

10. Clinical features
 The pain is ‘dull’, ‘tight’ or like a ‘pressure’
 It is of constant character and generalised, but
often radiates forwards from the occipital
region.
 The pain is usually less severe in the early
part of the day, becoming more troublesome
as the day goes on
 Activities are usually continued throughout,
and the pain may be less noticeable when the
patient is occupied

11. Management
 low-dose amitriptyline is often benifitial
 Excessive use of analgesia, particularly those
containing codeine, may maintain and
exacerbate the headache
 Physiotherapy (with muscle relaxation and
stress management) may help
 Most benefit is given by providing a careful
assessment, followed by discussion of likely
precipitants and reassurance

12. Migraine
 Usually appears before middle age
 More common in females

13. Pathophysiology
 Cause of migraine is unknown
 There is increasing evidence that the aura which
occurs before the headache is due to
dysfunction of ion channels causing a spreading
front of cortical depolarisation (excitation)
followed by hyperpolarisation (depression of
activity)
 The headache phase is associated with
vasodilatation of extracranial vessels and may
be relayed by hypothalamic activity

14.  The female preponderance and the frequency
of migraine attacks at certain points in the
menstrual cycle also suggest hormonal
influences
 Oestrogen-containing oral contraception
sometimes exacerbates migraine, and
increases the small risk of stroke in patients
who suffer from migraine with aura

15.  When psychological factors contribute, the
migraine attack often occurs after a period of
stress, being more likely on Friday evening at
the end of the working week or at the
beginning of a holiday

16. Clinical features
 Prodrome of malaise, irritability or behavioral
change for some hours or days can occur
 Around 20% of patients experience an aura
 The aura is most often visual, consisting of
fortification spectra, which are shimmering,
silvery zigzag lines
 In some there is a sensory aura of tingling
followed by numbness

17.  Migraine headache is usually severe and
throbbing, with photophobia, phonophobia and
vomiting lasting from 4 to 72 hours
 Movement makes the pain worse, and patients
prefer to lie in a quiet, dark room
 Structural disorders of the brain, or even focal
epilepsy, need to be considered during
assessment of an individual’s limb weakness
or isolated aura without headache to migraine

18. Management
 Avoidance of identified triggers or
exacerbating factors (such as the combined
contraceptive pill) may prevent attacks
 Acute attack- aspirin, paracetamol, NSAID
 Severe attacks can be aborted by one of the
increasing number of ‘triptans’ (e.g.
sumatriptan), which are potent 5-
hydroxytryptamine (5-HT) agonists

19.  If attacks are frequent (more than 3–4 per
month), prophylaxis should be considered
 Drugs used for prophylaxis- calcium channel
blockers, β-blockers, antidepressants
(amitriptyline) and anti-epileptic drugs
(valproate, topiramate)

20. Medication overuse headache
(MOH)
 Medication overuse headache (MOH) can
complicate any other headache syndrome, but
is especially associated with migraine and
tension headache
 Common culprits are compound
analgesia(particularly codeine and other
opiate-containing preparations) and triptans
 MOH is usually associated with use on more
than 10–15 days per month

21.  Management is by withdrawal of the
responsible analgesics

22. Cluster headache
 Cluster headaches is also known as
migrainous neuralgia
 There is a 5 : 1 male predominance

23. Pathophysiology
 Cause is unknown
 Functional imaging studies have suggested
abnormal hypothalamic activity

24. Clinical features
 Strikingly periodic in nature, featuring episodes
of identical headaches beginning at the same
hour for weeks at a time
 Causes severe, unilateral periorbital pain with
autonomic features, such as unilateral
lacrimation, nasal congestion and conjunctival
injection
 Pain is characteristically brief (30–90 minutes)
 The cluster period is typically a few weeks,
followed by remission for months to years

25. Management
 Acute attacks- subcutaneous injections of
sumatriptan or by inhalation of 100% oxygen
 Patients with severe debilitating clusters can
be helped with lithium therapy, although this
requires monitoring

26. Headaches associated with
specific activities
 These usually affect men in their thirties and
forties.
 Patients develop a sudden, severe headache
with exertion, including sexual activity.
 Lasts less than 10–15 minutes
 The pathogenesis of these headaches is
unknown.
 Patients only need reassurance and simple
analgesia

27. Other headache syndromes

28. Secondary headache
 May be due to structural, infective,
inflammatory or vascular conditions

29. At a glance

30. That’s all for now
Thank you