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Premium member Presentation Transcript 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 Psychological Headache 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 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: 184.108.40.206 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. 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 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. Slide 49: God Almighty Slide 50: Department of Otorhinolaryngology Professor & HOD Dr. Varadarajulu Professor Dr. K. Laxmanan Assistant Professors Dr. M.K. Srinivasan Dr. Muthubabu Dr. Vincent Prasanna Dr. Sakthivel Slide 51: 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 ----------- Slide 53: Many more Happy Returns of the Day …to our very own Pattasu “The Power” You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.