In the Name of God, Most Gracious, Most Merciful : In the Name of God, Most Gracious, Most Merciful Slide 2: Since time
immemorial… Slide 3: One Symptom… Slide 4: … Has always
been with us Slide 5: …With
Protean Etiologies Slide 6: Sparing no nation Slide 7: …Sparing no species Slide 8: Today… Slide 9: Mohammad Sadiq Introduction, Classification, Etiopathogenesis
Approach to a patient Slide 10: Naga Dharshini Migraine
Vascular Headaches Slide 11: Mukhilesh R. Headache in Otorhinolaryngology Slide 12: Mukesh G. Headache in Ophthalmology Slide 13: Nikkhil Gupta D. Headache in Neurology
Atypical Facial Pain Slide 14: Try to unravel Slide 15: The Enigma of… Slide 17: INTRODUCTION INTRODUCTION, ETIOPATHOGENESIS, CLASSIFICATION OF HEADACHE
APPROACH TO A PATIENT - Mohammad Sadiq
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
Proximal segment of large pial arteries PAIN SENSITIVE STRUCTURES: WHAT DOESN’T ACHE? : WHAT DOESN’T ACHE? Ventricular ependyma
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
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)
Cluster headache < 10% headaches
(Headaches due to
other medical problems)
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:
188.8.131.52 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)
Exacerbating & Relieving factors
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. Slide 40: MIGRAINE – C/F Slide 41: TENSION HEADACHE – C/F Slide 42: SINUSITIS – C/F Slide 43: OPTHALMIC CAUSES – C/F Slide 44: PSYCHOLOGICAL HEADACHE – C/F APPROACH TO THE PATIENT : APPROACH TO THE PATIENT ACUTE NEW-ONSET HEADACHE Meningitis
Purrulent sinusitis APPROACH TO THE PATIENT : APPROACH TO THE PATIENT CAUSES NOT TO BE MISSED!!! Intra-cranial tumours
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. Slide 49: God Almighty Slide 50: Department of Otorhinolaryngology
Professor & HOD
Dr. K. Laxmanan
Dr. M.K. Srinivasan
Dr. Vincent Prasanna
Dr. Sakthivel Slide 51: Special Thanks to
Mohammed Yaseen Sait M.A.
S. Shyam Sudhakar
Adnan Mohammad Matheen
Asgar Alam Sher Khan
----------- Slide 53: Many more
Happy Returns of the Day …to our very own Pattasu “The Power”