Headache

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In the Name of God, Most Gracious, Most Merciful : 

In the Name of God, Most Gracious, Most Merciful

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Since time immemorial…

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One Symptom…

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… Has always been with us

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…With Protean Etiologies

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Sparing no nation

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…Sparing no species

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Today…

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Mohammad Sadiq Introduction, Classification, Etiopathogenesis Approach to a patient

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Naga Dharshini Migraine Vascular Headaches

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Mukhilesh R. Headache in Otorhinolaryngology

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Mukesh G. Headache in Ophthalmology

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Nikkhil Gupta D. Headache in Neurology Psychological Headache Atypical Facial Pain

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Try to unravel

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The Enigma of…

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INTRODUCTION INTRODUCTION, ETIOPATHOGENESIS, CLASSIFICATION OF HEADACHE & APPROACH TO A PATIENT - Mohammad Sadiq Pre-Final yr.M.B.B.S. M.M.C.R.I.

HEADACHE : 

HEADACHE (= Cephalalgia) “Diffuse pain in various parts of the head, not confined to the area of distribution of any nerve” DEFINITION (Source: Stedman's Pocket Medical Dictionary)

HEADACHE : 

HEADACHE 90% of individuals have atleast one headache/yr! 40% of individuals suffer from severe disabling headache annually. 5% pts. presenting to the ER with headache are diagnosed to have a serious underlying neurological disorder. Headaches account for >8 million doctor visits/yr! Most people with a headache use nonprescription pain relievers to treat their symptoms. INCIDENCE

What causes headache?? : 

What causes headache?? Norm. physiological response mediated by a healthy NS Damage/inapp. Activation of pain sensitive pathways of CNS/PNS HEADACHE

WHAT ACHES? : 

WHAT ACHES? Scalp Middle meningeal artery Dural sinuses Falx cerebri Proximal segment of large pial arteries PAIN SENSITIVE STRUCTURES:

WHAT DOESN’T ACHE? : 

WHAT DOESN’T ACHE? Ventricular ependyma Choroid plexus Pial veins and…. PAIN INSENSITIVE STRUCTURES:

WHAT ABOUT BRAIN PARENCHYMA? : 

WHAT ABOUT BRAIN PARENCHYMA? MOST of the Brain Parenchyma is INSENSITIVE to pain. HOWEVER, in the region of the dorsal raphe in the MidBrain a site is sensitive to electrical stimulation. (Basis for central theory of migraine)

TRANSMISSION OF PAIN? : 

TRANSMISSION OF PAIN? Sensory stimuli from head ? CNS Supratentorial structures in anterior & middle cranial fossa Posterior cranial fossa & Infratentorial structures TRIGEMINAL NERVE C1, C2, C3 (Cervical spinal n.)

WHAT HAPPENS? : 

WHAT HAPPENS? Distension/traction/dilatation of intracranial or extracranial arteries. Traction/displacement of large i.c. veins/ their dural envelope. Compression/traction/inflam. of cranial & spinal n. Spasm/inflam/trauma to cranial & cervical muscles. Meningeal irritation & ? ICP. Other mechanisms (eg.: + of brainstem struc, ?endorphins). MECHANISMS OF HEADACHE

ETIOPATHOGENESIS : 

ETIOPATHOGENESIS Central theory (Dorsal raphe) Vascular theory (of Wolffe) Neurogenic inflammation theory (of Dr. Michael Moskowitz)

NEUROGENIC INFLAMMATORY THEORY : 

NEUROGENIC INFLAMMATORY THEORY Preventing neurogenic inflammation in the meninges at the periphery of the trigeminovascular system ? release of neuropeptides ? stim. of afferent nerve fibres Prevent headache pain

HEADACHE : 

HEADACHE CLASSIFICATION Primary Secondary > 90% headaches Tension (muscular contraction) Vascular (migraine) Cluster headache < 10% headaches (Headaches due to other medical problems) Traction headaches Inflam. headaches

CLASSIFICATION OF PRIMARY HEADACHE : 

CLASSIFICATION OF PRIMARY HEADACHE

CLASSIFICATION OF SECONDARY HEADACHE : 

CLASSIFICATION OF SECONDARY HEADACHE 5. Headache associated with head trauma, including: 5.1 Acute post-traumatic headache 5.2 Chronic post-traumatic headache 6. Headache associated with vascular disorders, including: 6.3 Subarachnoid haemorrhage 7. Headache associated with non-vascular intracranial disorders, including: 7.1.1 Benign intracranial hypertension 7.3 Intracranial infection 7.6 Intracranial neoplasm

CLASSIFICATION OF SECONDARY HEADACHE : 

CLASSIFICATION OF SECONDARY HEADACHE 8. Headache associated with substances or their withdrawal, including: 8.1.4 Acute alcohol induced headache 8.2.1 Chronic ergotamine induced headache 8.2.2 Chronic analgesics abuse headache 8.3.1 Alcohol withdrawal headache (hangover) 9. Headache associated with non-cephalic infection 10. Headache associated with metabolic disorder

CLASSIFICATION OF SECONDARY HEADACHE : 

CLASSIFICATION OF SECONDARY HEADACHE 11. Headache or facial pain associated with disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures, including: 11.2.1 Cervical spine 11.3.1 Acute glaucoma 11.5.1 Acute sinus headache 12. Cranial neuralgias, nerve trunk pain and deafferentation pain, including: 12.1.4.1 Herpes zoster 12.2 Trigeminal neuralgia 13. Headache not classifiable

I’ll Be Back… : 

I’ll Be Back…

APPROACH TO THE PATIENT : 

APPROACH TO THE PATIENT History, History, History (Headache diary) Site Onset Character Radiation Associated symptoms Timing Exacerbating & Relieving factors Severity State of health between attacks

APPROACH TO THE PATIENT : 

APPROACH TO THE PATIENT Extra-cranial SITE Intra-cranial Vascular PNS, Ocular, Dental, Upper cervical vertebral Giant cell arteritis ? precise loc. Less sharply localized but still regionally distributed Vascular Ant. & Mid. Cranial fossa Posterior Cranial fossa Frontotemporal pain Occipitonuchal pain

APPROACH TO THE PATIENT : 

APPROACH TO THE PATIENT ONSET Ruptured Aneurysm Cluster headaches Migraine Brain tumours/?ICP: Headaches that disturb sleep / early morning headaches.

APPROACH TO THE PATIENT : 

APPROACH TO THE PATIENT ONSET Early Morning Headache on waking up & again at end of day is due to Maxillary Sinusitis (diurnal variation). Office headache: due to Frontal sinusitis. [Patient wakes up mostly without pain (due to overnight drainage ? develops pain after a few hrs that last through out the day] Vaccum headache: headache on waking up that may occur in Frontal sinusitis due to overnight drainage.

APPROACH TO THE PATIENT : 

APPROACH TO THE PATIENT CHARACTER Dull aching pain: Sinusitis related Tension type: Tight “band like” pain Benign cranial pain: Jabbing, brief, sharp cephalic pain often multifocal (ice pick like) [BUT ///ar pain on face ? characteristic of neuralgic pain (lancellating pain)] Migraine: Throbbing w/ tight muscles around head, neck & shoulder girdle. Asso w/ aura mostly.

APPROACH TO THE PATIENT : 

APPROACH TO THE PATIENT INTENSITY Most important aspect of pain from patient’s point of view. BUT it rarely has diagnostic importance! Can often be misleading. Since even a brain tumour need NOT present with severe/distinctive pain.

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MIGRAINE – C/F

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TENSION HEADACHE – C/F

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SINUSITIS – C/F

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OPTHALMIC CAUSES – C/F

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PSYCHOLOGICAL HEADACHE – C/F

APPROACH TO THE PATIENT : 

APPROACH TO THE PATIENT ACUTE NEW-ONSET HEADACHE Meningitis Sub-arachnoid Hge Epidural/Subdural haematoma Glaucoma Purrulent sinusitis

APPROACH TO THE PATIENT : 

APPROACH TO THE PATIENT CAUSES NOT TO BE MISSED!!! Intra-cranial tumours Meningitis Subarachnoid haemorrhage Temporal arteritis Primary angle closure glaucoma Idiopathic intracranial hypertension Subacute carbon monoxide poisoning

HEADACHE : 

HEADACHE SUMMARY Headache is one symptom that may be the manifestation of a simple, benign problem like a tension headache or one of a life threatening fatal disease like a Berry aneurysm. Acute, new onset headache has a much more serious prognosis than other types of onsets. So a careful evaluation of the etiology of headache is very essential. Symptomatic treatment of headache must NOT precede evaluation of its cause.

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God Almighty

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Department of Otorhinolaryngology Professor & HOD Dr. Varadarajulu Professor Dr. K. Laxmanan Assistant Professors Dr. M.K. Srinivasan Dr. Muthubabu Dr. Vincent Prasanna Dr. Sakthivel

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Special Thanks to Mohammed Yaseen Sait M.A. S. Shyam Sudhakar B. Harshavardhan Adnan Mohammad Matheen Akmal A Asgar Alam Sher Khan Anmol Goyal Aravind G Aravind Raj -----------

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Many more Happy Returns of the Day …to our very own Pattasu “The Power”

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