2. References
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Davidsons principles and practice of medicine 19th
edition
Neuro ophthalmology section 5 AAO series 2004-
2005
Oxford hand book of ophthalmology 2006
The wills eye manual
www.wikipedia.com
4. Introduction
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A headache or cephalagia
is pain anywhere in the
region of head or neck
Can be a symptom of a
number of different
conditions of head and
neck
Ref: headache at Dorland’s Medical
Dictionary
5. Introduction
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Headache in itself is not a disease but merely a
symptom of a disease.
A symptom which may accompany many different
types of conditions.
May be a manifestation of a syndrome such as
migraine.
May be sight threatening or life threatening
6. Contd…
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The frequency and severity of headache attacks
determine the extent to which the headache problem
will incapacitate the patient.
That’s why headache represents an item of extreme
economic and social importance
Headache is a frequent reason given for absenteeism
at work .
It is also a factor which will universally tend to lower
the individual’s efficiency while s/he is working.
7. Contd…
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Since head is the most frequent site of pain and
discomfort almost everybody has a headache at one
time or other.
It is a warning signal to say something wrong within
the organism or enviroment.
8. History
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Migraine , neuralgia ,shooting head pain have been
documented in medical literature of 1550 BC
Hippocrates in 460 BC described visual symptoms
associated with MIGRAINE
Aretacus in AD 80 described that the pain of
migraine is unilateral
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The first recorded classification system that
resembles the modern ones published by Thomas
Willis, in De Cephalagia in 1672
In 1787 Christian Baur divided headaches into
idiopathic (primary headache) and symptomatic
(secondary ones) and defined 84 catagories
Contd…
11. Epidemiology
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During a given year,90% of people suffer from
headaches
Of the ones seen in the ER , about 1% have a serious
underlying problem
Primary headache accounts for more than 90% of all
headache complaints and of these episodic tension
headache is the most common
Ref: headache pathophysiology retrieved june 21-2010
12. Contd…
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Annual cost through lost work and impaired
effectiveness may be £1.5 billion
Migraine appears to be exclusively experienced by
12% - 18% of the population
Cluster headache are thought to affect less than 0.5%
of the population
Cluster headache are more likely to occur in men
than women, tends to affect 5 to 8 times more men
Migraine headache more common in female(3:1)
Ref: British research of headache 2007
13. Classification
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Thoroughly classified by International Headache
Society’s International Classification of Headache
Disorders (ICHD) which published its second edition
in 2004
This classification is accepted by WHO
14. International classification of headache
disorders(ICHD)
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Classification uses numeric codes
The top, one-digit diagnostic level includes 13 groups
First four group classified as primary headaches,
group 5-12 as secondary headache
Cranial neuralgia, central and primary facial pain
and other headaches for the last two groups
ICHD-2 classification defines migraine, tension-
types headaches, cluster headache and other
trigeminal autonomic cephalalgias as the main type
of primary headache
15. Contd…
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Secondary headache are classified based on their
etiology not their symptoms
ICHD-2 includes secondary headaches due to head
and neck trauma such whiplash injury, intracranial
hematoma , post craniotomy and other head and
neck injury
Headache caused by ischemic stroke and transient
ischemic attack, non traumatic intracranial
hemorrhage, vascular malformation or arteritis are
also secondary headache
16. Contd…
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Headache caused by epileptic seizure, HIV/AIDS,
intracranial infections and systemic infections are
also secondary headache
Headache caused by dialysis, HTN , hypothyroidism,
injury to jaws ,teeth or temporomandibular joints,
fasting and even psychotic disorders are also
classified as secondary headache
17. New classification
In 2007 the International Headache Society agreed
upon an updated classification system for headache.
the new classification system will allow health care
practitioners come to a specific diagnosis as to the
type of headache and to provide better and more
effective treatment.
1. primary headaches
2.secondary headaches
3. cranial neuralgias, facial pain, and other headaches
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18. What are primary headaches?
Primary headaches include migraine, tension, and
cluster headaches, as well as a variety of other less
common types of headache.
Tension headaches are the most common type of
primary headache. Up to 90% of adults have had or
will have tension headaches. Tension headaches
occur more commonly among women than men.
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19. Contd…
Migraine headaches are the second most
common type of primary headache. An estimated 28
million people in the United States (about 12% of the
population) will experience a migraine headache.
Migraine headaches affect children as well as adults.
Before puberty, boys and girls are affected equally
by migraine headaches, but after puberty, more
women than men are affected.
It is estimated that 6% of men and up to 18% of
women will experience a migraine headache in their
lifetime.
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20. Contd…
Cluster headaches are a rare type of primary
headache affecting 0.1% of the population (1 in a
1,000 people). It more commonly affects men in
their late 20s though women and children can also
suffer these types of headache.
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21. What are secondary headaches?
Secondary headaches are those that are due to an
underlying structural problem in the head or neck.
There are numerous causes of this type of headache
ranging from bleeding in the brain, tumor, or
meningitis and encephalitis.
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22. Pathophysiology
Different for various types
Headache of intracranial origin
Brain itself is not sensitive to any nociceptive stimuli
Venous sinuses , major arteries and large veins , spinal
nerves, head and neck muscles and meninges at base of
skull and sensory cranial nerves---- pain sensitive
Any sort of traction, distortion , irritation or inflammation
of these pain sensitive structure----- Headache
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23. Ocular headache
Muscle contraction
Glaucoma is due to rise in IOP and involvement of
posterior cilliary Artery
Sinus headache
Common site – frontal and maxillary regions
i) congestion of mucosa
ii) ducts and ostial blocks
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24. Nerve pathway for pain
Trigeminal nerve carries pain sensation from
-anterior 2/3 of head
-upper surface of tentorium
- supratentorial surface
Pain from these structure felt in the distribution of V
nerve( ant. Part of head)
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25. Contd…
Pain from infratentorial region , post.fossa , and post. One
third of head (upper 3 cervical nerves)
posterior part of head and neck
Overlap between trigeminal and upper 3 cervical nerves
occurs –referred pain from anterior structure to posterior
and vice
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27. Non Ocular Causes Of Headache
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1) Tension-type headache
2) Vascular headache
A) Migraine headache
Migraine with aura (classic migraine)
Migraine without aura (common migraine)
Complicated migraine
Hemiplegic migraine
Ophthalmoplegic migraine
Basilar artery migraine
B) Cluster headache
C) Systemic infection
D) Hypoxia
E) Systemic hypertension
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3) Head trauma
4) Headache due to disorders of head and neck
structures
a) Head and neck disorders
b) Ear and sinus disorders
c) Mouth and jaw disorders
5) Intracranial infections
a) Meningitis
b) Encephalitis
c) Brain abscess
30. Ocular causes of Headache
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Three categories
a) headache due to refractory error and
eye muscle weakness
b) headache due to secondary
diseases of eye
c) those due to systemic disorders having
prominent ocular symptom
31. A) Refractory error and muscle
weakness
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Mainly in afternoon or evening at the end of work
Hypermetropia and astigmatism
Low grade refractory error is main cause
Starts as heaviness in eye and continuous
use of eye leads to headache
Ocular muscle imbalance as latent squint and
convergence insufficiency cause headache
Accommodative insufficiency also causes headache
Lack of fusional capacity also causes headache
32. B) Secondary to eye diseases
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Acute angle closure glaucoma
Acute iritis
Keratitis
Ocular ischemic syndrome
33. C) Systemic disorders with visual
symptoms
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Raised intra cranial pressure
Migraine
Temporal arteritis
Psychogenic
34. Headache as dangerous sign
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Medication overuse headache may occur in those
using excessive painkillers for headache ,
paradoxically causing worsening headaches
Life threatening headache are known as “red flag”
symptoms like thunderclap headache(develops
within minutes), inability to move a limb or
abnormalities on neurological examination, mental
confusion, headache that worsens with change in
posture, headache worsened by exertion or Valsalva
manoeuvre (coughing, straining)
35. Contd..
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Headache associated with visual loss or jaw
claudication (jaw pain on chewing that resolves
afterwards), neck stiffness, fever and headaches in
people with HIV, cancer or risk factors for
thrombosis
Thunderclap headache may be the only symptom of
subarachnoid hemorrhage from brain aneurysm
Headache in fever may be due to meningitis and
confusion may be indicative of encephalitis
36. Contd…
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Headache worsening with posture may be indicative
of brain tumors, idiopathic intercranial hypertension
and cerebral venous thrombosis
Headache associated with weakness is indicative of
stroke
Headache with visual loss and jaw claudication is
indicative of giant cell arteritis (GCA)
Headache in glaucoma(AACG) is due to rise in IOP
and involvement of posterior ciliary artery
37. History taking
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A) Location-
frontal- sinusitis
temporal- temporal arteritis
occipital- tension, orthoptic problem
unilateral- migraine
frontal & parietal- refractive error
B) Intensity
mild- tension
very severe-raised ICP, papilledema
38. Contd…
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C) Frequency- once and twice in a month
and mild type may not be significant
D) Nature-
throbbing- migraine
constricting- tension
E) Time of occurrence
afternoon and evening- ocular
worsening in morning- raised ICP
sinusitis
39. Contd…
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F) Age of onset
childhood /teenage-refractory error
accommodative
convergence
fusional insuffiency
middle aged ----- hypertension
old age ------ GCA
intracranial
tumour
40. Contd…
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G) Relieving factor
- improve with rest or mild NSAID
usually mild type
- not responding to pain killer which was
previously used to respond may be dangerous
41. Contd…
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H) Other associated symptoms
according to suspected etiology
e.g. i) ENT problems
ii) dental problems
iii) anxiety or depressive symptom
iv) fever
v) feature of raised ICP
(diplopia ,vomiting)
42. Evaluation of eye in a patient with
headache
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Importance
i) may harbour a life threatening disease e.g. intra
cranial neaoplasm
ii) ophthalmologist detects it by finding
papilloedema early
field defect cranial
nerve involvement
iii) early diagnosis may be life saving
44. Contd…
Transient loss of vision (Amaurosis Fugax)
i) migraine
ii) severe hypertension
iii) papilledema
iv) GCA
B) Ocular motility
restricted in Ophthalmoplegic migraine
C) Cover test/uncover test – to rule out PHORIA
and TROPIA
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47. Contd…
Refraction – both with and without
cycloplegic
Orthoptic - for evaluation of
convergence,accommodative and fusional
insufficiency and phorias
Visual field
Gonioscopy
Detail neurological, ENT, dental, and
psychiatric evaluation will be needed according
to associated symptoms
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48. Investigations
Should be done according to suspected cause and associated
symptoms
i) x ray PNS - to R/O sinusitis
ii) ESR /temporal artery biopsy
iii) CT or MRI - to R/O intra cranial pathology
iv) Carotid flow study - ocular ischemia
v) Lumbar puncture - meningitis
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