2. Sahar yusuf Alkadi
Prepared by:

3. Lecture Outline
• Headaches Introduction
• Sensitive structures in the skull
• Headache ‘red flags’Diagnosis
• Patho-physiology
• Etiology
• Classification of headaches
• History : Profile of HA
• Home care for headaches
• Material to read later-Case StudyMaterial to read later-Case Study

5. Definition:
Pain or discomfort
from the level of
the brows to the
suboccipital
region

7. WhyWhy????

8. Sensitive structures in the skull
1. All the tissue covering the bone except
the hair
2. Cerebral arteries
3. Venous sinuses
4. Cranial nerves: 5,9,10 & upper 3 cervical
nerves
5. Meninges: especially the basal
N.B: the Brain itself is insensitive

9. Origins of Pain in the Head
Extra-cranial pain sensitive
structures:
Intra-cranial pain sensitive
structures:
 Sinuses
 Eyes/orbits
 Ears
 Teeth
 TMJ
 Blood vessels
 Arteries
 Veins
 Meninges
 Dura

10. Headache ‘red flags’
New onset headache in middle age or later
;and progressive headache, especially in middle-
age >50 (giant cell arteritis)
New or progressive headache that lasts for days
Headache with neurologic symptoms
Systemic symptoms (neck stiffness, fever, nausea,
Vomiting, weight loss ,blurry or double vision )
or Secondary risk factors (HIV, systemic cancer)

13. Nerve involved :
- Trigeminal nerve
- First 3 cervical nerve
- Facial nerve
- Glosso-pharyngeal & vagus nerve

14. Etiology
1) Vascular headache : (V.D.)
Migraine
Hypertension & Hypoxia & Hypoglycemia
Arteritis & Aneurysm
Toxic: Caffeine withdrawal & Alcohol
 renal and hepatic failure
2) Traction Headache: (Space occupying lesion )
due to stretch of Meninges as in brain tumors

15. 3) Tension Headache: (Psychogenic headache )
Cap-like constriction (Ache pain)
Not localized & Not throbbing & Don’t increase
with Straining
Usually associated with depression, neurosis &
stress
4) Meningeal irritation:
Meningitis
Subarachnoid hemorrhage
5) Muscle contraction headache:
Prolonged contraction of the muscles of the head
and neck e.g: prolonged driving

16. 6) Neuritis and neuralgia:
Of the sensory nerves of the scalp e.g.: trigeminal
neuralgia
7) Referred headache: may be very sever
Eye: iritis, glaucoma
Ear: middle ear diseases
Nasal sinuses diseases
Teeth diseases and Tongue diseases

17. Classification of headaches
Primary headaches
OR Idiopathic headaches
THE HEADACHE IS ITSELF THE
DISEASE
NO ORGANIC LESION IN THE
BEACKGROUND
TREAT THE HEADACHE!
Secondary headaches
OR Symptomatic headaches
THE HEADACHE IS ONLY A
SYMPTOM OF AN OTHER
UNDERLYING DISEASE
TREAT THE UNDERLYING
DISEASE!
The differentiation between 1° and 2° is critical as it dictates
diagostic approach and guides treatment and prognosis.

18. *Migraine
*Thunderclap
headache (TCH)-
sudden onset
Exertional headache
Cough headache
*Tension type of
headache
*Cluster headache
Other, rare types of
primary headaches
*Sexual headache
(Coital Cephalgia)
deBruijn, SF, et al. Lancet. 1996; Lancet. 1998.

19. Episodic headache disorder characterised by combinations of
changes:
Neurological, Gastrointestinal, Autonomic
Definition
A neurologic disorder characterised by idiopathic,
paroxysmal, recurrent attacks of headache lasting from 2-72
hours
Typical characteristics:
 Unilateral (sometimes bilateral)
 pulsating quality
 mod or severe intensity
 may be accompanied by either nausea & vomiting or
photophobia & phonophobia
 aggravated by physical activity
 may be preceded by an aura
Definition of Migraine headache

21. .The Most common type of 1ry headache, TTH accounts for
nearly 90% of all headaches. Approximately 3% of the
population has chronic tension-type headaches.
.lasting 30 min to 7 days.
.The pain not only occurs in the head and neck, but also
radiates around the face and scalp muscles.
.This is a type of muscle contraction pain.
.It is more in females than males.

22. - The exact cause of tension headache is
unknown.
- it’s thought to occur due to stress, tension,
depression, bad posture, staying in one
position for long time, or caffeine.

23. . Adult or tightness pain around the
head , band like
. Pain radiates down to the neck.
. The pain is bilateral, vary in intensity.
. Not associated with aura, nausea, vomiting,
or light or sound sensitivity.
.sever in early part of the day and less as day
goes.
.continue for weeks or months without
interruption

26. ..Tension headache is usually treated with the
help of over-the counter medications(pain-
killers) as: aspirin ,acetaminophen or naproxen .
..If these fail , other supportive ttt are available
as: massage & stress management.
..If recurrent headache , should seek for medical
help.

27. Prophylactic treatment of the chronic
tension type of headache
Tricyclic antidepressants
Guidelines:
• Start with low dose (10-25 mg) and increase the
dose if no beneficial effect after 1-2 weeks
• Maximal dose should not be more than 75
mg/day
• Change to other tricyclic antidepressant only
after 6-8 weeks
• Ask the patient to use headache diary
• Use the tricyclic antidepressant for 6-9 months
• Decrease the dose gradually

28. Prophylactic treatment of the chronic
tension type of headache
First choice of drug:
Amitryptiline or Mirtazapine
1st week: 25 mg in the evening
2nd week: 50 mg in the evening
3rd week: 75 mg in the evening continuously
Change to other drug (e.g. clomipramine) if no
beneficial effect within 6 weeks

29. is one of the most painful types of headache..
- Is avascular headache that causes extreme
pain.
- Occur for several days or weeks at the same
time of the day.
- It’s more common in men, especially smokers.
- It begins in adolescence but can extend to
middle age.
- There are 2 types of cluster headache:
. Episodic
. Chronic

30. Causes of cluster headache:
. the cause of cluster headache is unknown.
.it’s brought to occur due to:
1- dilation of blood vessels.
2- inflammation of the nerves present behind eyes.
3- bright sunlight, smoking, drinking alcohol and some
foods as: chocolate or foods high in nitrites like
smoked meats may trigger cluster headache.
4- tend to run in families& this suggest that there may
be areole for genetics.
5- may be due to changes in sleep patterns.
6- may be triggered by medication as: nitroglycerin
which used for heart disease.

31. Symptoms of cluster headache:
1- sever unilateral per orbital pain accompanied by: unilateral
lacrimation , nasal congestion..
(dull, steady pain ,some pt. describe the pain as feeling like a hot
poker in the eye, the affected eye may become red, inflamed and
watery ,also the nose of the affected side may become
congested and runny).
2- attack occur at the same time every day , lasting for 30 to 90
min , often awaken the pt. at night from a sleep.
3- once or twice daily or more than twice followed by respite for
months before another cluster occur — known as cluster periods .
4- tend to be restless which make the pt. to pace the floor or
bang their head against a wall.
5- nausea and vomiting rarely occur.
6-symptoms develop in early hours of morning

33. - There’s no specific ttt for cluster headache.
-- However ttt help in reliving the symptoms as well as
help prevent more attacks.
Some of these ttt include:
1. Inhalation of high concentration oxygen: the pt. is
required to wear an oxygen mask that help increase the
amount of oxygen in blood , thus relaxing the blood
vessels and providing pain relief.

34. 2. Injection of triptan medication as, sumatriptan
which is common migraine medication.
3. Injection of lidocaine ,local anasthetic into the
nostril.
4. caffine.

35. Prevention of the next cluster headache
include the following:
1- calcium channel blocker as verapamil.
2- prednisolone.
3- antidepressant medication.
4- lithium.
5- antiseziure medication as valproic acid.
.also life style changes may help to
minimize the risk of cluster headache as
stop smoking and alcohol.

36. Prophylactic treatment of the episodic
form of cluster headache
Episodic form: prednisolone
Treatment:
1-5. days 40 mg
6-10. days daily 30 mg
10-15. days daily 20 mg
16-20. days daily 15 mg
21-25. days daily 10 mg
26-30. days daily 5 mg
Nothing
Intravenous magnesium sulfate relieves cluster headaches in about 40%
of patients with low serum ionized magnesium levels. Melatonin has
also been demonstrated to bring significant improvement in
approximately half of episodic patients

37. Prophylactic treatment of the chronic
form of cluster headache
Lithium carbonate
Daily 600-700 mg
Can be decreased after 2 weeks remission
Control of serum level is necessary
(0,4 - 0,8 mmol/l)
Methysergide (synthetic ergot alkaloid), and
the anticonvulsant topiramate are
alternative treatments.

38. DuboseDubose et alet al (1995); Goadsby (1999); Marks and Rapoport (1997)(1995); Goadsby (1999); Marks and Rapoport (1997)
Family historyFamily history YesYes
SexSex More femalesMore females
OnsetOnset VariableVariable
LocationLocation Usually unilateralUsually unilateral
in adultsin adults
Character/severityCharacter/severity PulsatilePulsatile
ThrobbingThrobbing
Frequency/Frequency/ 2–72 h/attack2–72 h/attack
durationduration 1 attack/year to1 attack/year to
>8 per month>8 per month
AssociatedAssociated Visual auraVisual aura
symptomssymptoms PhonophobiaPhonophobia
PhotophobiaPhotophobia
PallorPallor
Nausea/vomitingNausea/vomiting
Clinical featureClinical feature MigraineMigraine
NoNo
More malesMore males
During sleepDuring sleep
Behind/aroundBehind/around
one eyeone eye
Excruciating/Excruciating/
sharpsharp
SteadySteady
15–90 min/attack15–90 min/attack
1–8 attacks/day1–8 attacks/day
for 3–16 weeksfor 3–16 weeks
1–2 bouts/year1–2 bouts/year
SweatingSweating
Facial flushingFacial flushing
Nasal congestionNasal congestion
PtosisPtosis
LacrimationLacrimation
Conjunctival injectionConjunctival injection
Pupillary changesPupillary changes
Cluster headacheCluster headache
YesYes
More femalesMore females
Under stressUnder stress
Bilateral in bandBilateral in band
around headaround head
DullDull
Persistent Tightening/pressingPersistent Tightening/pressing
30 min to 7 days30 min to 7 days
3–4 attacks/week3–4 attacks/week
to 1–2 attacks/yearto 1–2 attacks/year
Mild photophobiaMild photophobia
Mild phonophobiaMild phonophobia
AnorexiaAnorexia
Tension headacheTension headache

40. refers to a severe headache of
sudden onset. Its explosive and
unexpected nature is likened to a
"clap of thunder.”

42. - are headaches brought on by sexual activity.
- You may notice a dull ache in your head and neck
that builds up as sexual excitement increases
- you may experience a sudden, severe headache
just before or during orgasm.( Obviously, sex raises
the blood pressure. This in turn raises the pressure in
the head. Also, sex causes muscle tightening and
tension.) Sex headaches are a combination of the
blood pressure and muscle tension, for most people.

45. Trigeminal neuralgia
Lancinating pain in 2nd
,3rd
division
of trigeminal nerve
Usually in pt. over the 50 yrs.

46. Clinical features
Sever, very brief but repetitive
Precipitated by touching trigger
zones within the trigeminal
territory by cold wind blowing on
the face or by eating

47. Management
1-Carbamazepine more than
1200mg/daily
2-Gabapentin or pregabalin

48. Hypnic headaches
Tend to occur in the elderly,
women>men. Occur particularly at night,
waking patient during REM stages of
sleep. Characterized by throbbing,
without autonomic features, may last
upto 1 hr and reoccur through the night.

52.  Cluster headache
 Short, excruciating (15 min-3 hrs)
 Usually occur in the middle of the night
 unilateral pain behind eye
 occur daily for 2-3mths then remit for months-years
 Red, watering eyes, blocked nose
 Tension headache
 diffuse pain in tight head-band pattern
 bilateral, non-pulsating
 no prodrome/aura
 No nausea and vomiting
 10 attacks lasting 30 min–7 days
 2 of the following 4
 Bilateral
 Not pulsating
 Mild or moderate intensity
 Not aggravated by routine physical activity
 No nausea or vomiting
 One or neither photophobia or phonophobia
 Not attributable to another disorder
 Sinus headache
 Evidence of purulent discharge from the nose
 constant dull ache in cheek area accompanied by sinusitis
 worsens with bending over or blowing nose
Differential diagnosis of primary headaches

54. SECONDARY – (structural or metabolic
abnormality):
• Extra-cranial: sinusitis, otitis media,
glaucoma, TMJ ds
• Intra-cranial: SAH, vasculitis,
dissection, central vein thrombosis,
tumor, abscess, meningitis
• Metabolic disorders: CO2 retention,
CO poisoing

55. History : Profile of HA
time from onset to peak
usual time of onset (week
, month, season, hour of
day)
frequency & duration
change over lifetime
description : pulsating,
pressing, sharp
location : unilateral or
bilateral or changing
severity
precipitating factors
Aggravating factors
factors that relieve the
headache
effectiveness of
pharmacological or non-
pharmacological
treatments
Aura

56. Giant cell arteritis syn Arteriitis
temporalis syn temporal arteritis
• Giant cell arteritis (GCA or temporal arteritis) is an autoimmune
disease, granulomatose inflammation of branches of External Carotid
Artery that supply the head eyes, and optic nerves . It is a form of
vasculitis.
• The name (giant cell arteritis) reflects the type of inflammatory cell
that is involved (as seen on biopsy).
• The terms "giant cell arteritis" and "temporal arteritis" are
sometimes used interchangeably, because of the frequent involvement
of the temporal artery.

57. Epidemiology:
It is more common in females than males by a ratio of 3:1. The
mean age of onset is about 70 years, and it is rare in those
less than 50 years of age. The incidence is 24.2 per 100,000
women over 50 and 8.2 per 100,000 men over 50

58. Clinical Presentation:
•Unilateral headache, pulsating pain more sever at night
•Fever
•Tenderness and sensitivity on the scalp
•Jaw claudication (pain in jaw when chewing) 
inflammation of internal maxillary artery
•Tongue claudication (pain in tongue when chewing) and
necrosis
•Reduced visual acuity (blurred vision)
•Acute visual loss (sudden blindness)
•Diplopia (double vision)
•Acute tinnitus (ringing in the ears)
•Approximately 50% of GCA patients also have
polymyalgia rhematica (PMR), which is characterized by
muscle pain and stiffness.
•The inflammation may affect blood supply to the eye
and blurred vision or sudden blindness may occur. In
76% of cases involving the eye, the ophthalmic artery is
involved causing anterior ischemic optic neuropathy.
Loss of vision in both eyes may occur very abruptly and
this disease is therefore a medical emergency.
Amaurosis fugax may precede the blindness

59. Treatment
Corticosteroids, typically high-dose
prednisone (40–60 mg bd), must be
started as soon as the diagnosis is
suspected (even before the diagnosis is
confirmed by biopsy) to prevent
irreversible blindness secondary to
ophthalmic artery occlusion. The dose
of prednisone is lowered after a 2–4
weeks, and slowly tapered over the
course of 9–12 months. Oral steroids
are at least as effective as iv steroids,
except in the treatment of acute visual
loss where iv steroids appear to offer
significant benefit over oral steroids

60. Home care for headaches :
Headaches make life difficult , those who suffer from regular
headaches ,will agree with this statement .
.. When a headache strikes , one should follow some simple
home care tips that help relieve the symptoms to some extent .
These include :
- First and foremost , if possible , rest , it is very important that
you leave all works aside & rest in a quiet dark room .
- At times , a light sleep helps relieve the stress that causes
headaches .
- You can place a light , cool cloth over the head as it helps you
relax .
- Use painkiller .

62. Material to read later-Case Study
 17 yr old female
 L-sided pulsatile headache recurring 3-4x monthly
 headache preceded by loss of visual fields
 headache is accompanied by nausea, vomiting and
photophobia
 headache lasts all day unless able to lie in a dark room &
sleep
 affects ability to work/study
 past medical history unremarkable - no other medical
problems
 general physical & neurologic exam -normal

63. Thank
you