Headache and Ophthalmology (brief overview): Dr. Pradeep Bastola

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BRIEF OVERVIEW OF HEADACHE AND EYE Dr. Pradeep Bastola MD, Ophthalmologist, Gandaki Medical College, Charak Hospital, Kaski, Pokhara, Nepal 2.10.2010

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Ophthalmologists are usually the first doctors to see a patient of headache

Headache = Cephalgia : 

Headache = Cephalgia Diffuse pain in various parts of the head not confined to distribution of any particular nerve. (Source: Stedman’s pocket medical dictionary)

Incidence/Importance : 

Incidence/Importance 90% of the individuals at least experience an episode of headache in a year. 40% of individuals suffer from severe disabling headache annually. 5% of patients presenting with severe headache to emergency department have serious underlying disorder.

Contd………. : 

Contd………. Headache accounts for more than 8 million doctor visits per year. Majority of the patients use non prescription medication to relieve the symptoms.

WHAT ACHES? : 

WHAT ACHES? Scalp, middle meningeal artery, dural sinuses, falx cerebri, proximal segment of large pial arteries

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

Good History taking : 

Good History taking “Listen to the patient, He is telling you the diagnosis” - Dr William Osler We interrupt in 30 secs* Headache (primary c/t?) Mild / mod /severe - Is it debilitating? (subjective) *Svab I. The time used by the patient when he/she talks without interruptions. Aten Primaria 1993;11: 175-7. Blau JN. Time to let the patient speak. BMJ 1989;298: 39.

International headache society (1988) – Classification of CephalgiaUpdated classification IHS (1994) : 

International headache society (1988) – Classification of CephalgiaUpdated classification IHS (1994) 1. Migraine 1.1 Migraine without aura 1.2 Migraine with aura 1.3 Ophthalmoplegic migraine 1.4 Retinal migraine 1.5 Childhood periodic syndromes that may be precursors to or associated with migraine 1.6 Complications of migraine 1.7 Migrainous disorder not fulfilling above criteria

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2. Tension-type headache 2.1 Episodic tension-type headache 2.2 Chronic tension-type headache 2.3 Tension-type headache not fulfilling above criteria 3. Cluster headache and chronic paroxysmal hemicrania 3.1 Cluster headache 3.2 Chronic paroxysmal hemicrania 3.3 Cluster headache–like disorder not fulfilling above criteria

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4. Miscellaneous headaches not associated with structural lesions 4.1 Idiopathic stabbing headache 4.2 External compression headache 4.3 Cold stimulus headache 4.4 Benign cough headache 4.5 Benign exertional headache 4.6 Headache associated with sexual activity

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5. Headache associated with head trauma 5.1 Acute posttraumatic headache 5.2 Chronic posttraumatic headache. 6. Headache associated with vascular disorders 6.1 Acute ischemic cerebrovascular disorder 6.2 Intracranial hematoma 6.3 Subarachnoid hemorrhage 6.4 Unruptured vascular malformation 6.5 Arteritis

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6.6 Carotid or vertebral artery pain 6.7 Venous thrombosis 6.8 Arterial hypertension 6.9 Headache associated with other vascular disorder 7. Headache associated with nonvascular intracranial disorders 7.1 High CSF pressure 7.2 Low CSF pressure 7.3 Intracranial infection

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7.4 Intracranial sarcoidosis and other noninfectious inflammatory diseases 7.5 Headache related to intrathecal injections 7.6 Intracranial neoplasm 7.7 Headache associated with other intracranial disorders 8. Headache associated with substances or their withdrawal

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8.1 Headache induced by acute substance use or exposure 8.2 Headache induced by chronic substance use or exposure 8.3 Headache from substance withdrawal (acute use) 8.4 Headache from substance withdrawal (chronic use)

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8.5 Headache associated with substances but with uncertain mechanism 9. Headache associated with noncephalic infection 9.1 Viral infection 9.2 Bacterial infection 9.3 Headache related to other infection 10. Headache associated with metabolic disorders 10.1 Hypoxia 10.2 Hypercapnia 10.3 Mixed hypoxia and hypercapnia

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10.4 Hypoglycemia 10.5 Dialysis 10.6 Headache related to other metabolic abnormality 11. Headache or facial pain associated with disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cranial structures 11.1 Cranial bone 11.2 Neck

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11.3 Eyes 11.4 Ears 11.5 Nose and sinuses 11.6 Teeth, jaws, and related structures 11.7 Temporomandibular joint disease 12. Cranial neuralgias, nerve trunk pain, and deafferentation pain 12.1 Persistent (in contrast to tic-like) pain of cranial nerve origin

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12.2 Trigeminal neuralgia 12.3 Glossopharyngeal neuralgia 12.4 Nervus intermedius neuralgia 12.5 Superior laryngeal neuralgia 12.6 Occipital neuralgia 12.7 Central causes of head and facial pain other than tic douloureux 12.8 Facial pain not fulfilling criteria in groups 11 or 12 13. Headache not classifiable

Ocular causes for headache : 

Ocular causes for headache Ocular migraine 1. Ophthalmoplegic migraine 2. Retinal migraine 3. Migraine with aura 4. Common Migrane Refractive errors Accommodative spasm Acute iridocyclitis Other forms of uveitis

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Acute congestive glaucoma (Ocular emergency) Scleritis (Posterior) Episcleritis (Uncommon) Primary angle closure glaucoma Other forms of glaucoma Computer vision syndrome Trauma to the eye (Ocular emergency)

Ruptured globe : 

Ruptured globe

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Herpes zoster Ophthalmicus Optic neuritis (Retrobulbar) Multiple sclerosis Intraocular tumor Intraorbital tumor Orbital cellulitis (Ocular emergency) Cavernous sinus thrombosis (Ocular emergency)

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Carotido Cavernous Fistula Recent onset third nerve palsy (Neuro surgical emergency when pupil involved) Metastatic carcinoma to the eye or orbit Adenoid cystic carcinoma (perineural invasion) _ lacrimal gland

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Idiopathic orbital inflammation (Pseudo tumor oculi) Tolosa Hunt Syndrome/Orbital Apex Syndrome Hordeolum Externum Hordeolum Internum Corneal infections (Ocular emergency)

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Tension headache Trigeminal neuralgia (prosopalgia) Endophthalmitis/Panophthalmitis Cluster headache (Suicide headache) Headache due to increased Intra Cranial pressure (ICP) (ICSOL) Pontine haemorrhage Idiopathic intracranial hypertension (Pseudo tumor cerebri) Miscellaneous Cluster headache

Trigeminal nerve, sensory distribution : 

Trigeminal nerve, sensory distribution

Visual Disturbances of Migraine : 

Visual Disturbances of Migraine History “He seemed to see something shimmering before him like a light…a violent pain supervened in the right temple, then all in the head and neck…” Hippocrates

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John Fothergill (Quaker Physician)“…it begins with a singular kind of glimmering in the sight, objects swiftly changing their apparent position, and surrounded with luminous angles like those of a fortification.” Reported by R.H. Fox 1919

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Sir Hubert Airy (1871): Published “On a distinct form of transient hemianopia” coining the term “teichopsia” (Greek: teichos=fortification and opsia=seeing) X. Galezowski(1882): “ophthalmic megrim” in 3 migraineurs with CRAO C.M. Fisher(1952): Migrainous amaurosis fugax

Migraine Aura : 

Migraine Aura K. Lashley calculated rate of progression of migraine scotoma as 3mm/min over cortex (1941) Spreading cortical depression (3mm/min) of Leão (1944) P. Milner(1958): “..attention should be drawn to the striking similarity between the time courses of scintillating scotomas and Leão’s spreading depression..”

Migraine (Clinical diagnosis) : 

Migraine (Clinical diagnosis) Migraines are underdiagnosed and often misdiagnosed. The diagnosis of migraine without aura, according to the International Headache Society, can be made according to the following criteria, the "5, 4, 3, 2, 1 criteria“ 5 or more attacks. [For migraine with aura, only two attacks are sufficient for diagnosis] 4 hours to 3 days in duration. 2 or more of the following: Unilateral (affecting half the head); Pulsating; "Moderate or severe pain intensity"; "Aggravation by or causing avoidance of routine physical activity".

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1 or more of the following: The mnemonic POUNDing (Pulsating, duration of 4–72 hOurs, Unilateral, Nausea, Disabling) can help diagnose migraine. If 4 of the 5 criteria are met, then the positive likely hood of diagnosing migraine is very high.

Matharu M, Goadsby P (October 2001). "Cluster Headache -- Update on a Common Neurological Problem" (PDF). Practical Neurology 1: 42–9. : 

Matharu M, Goadsby P (October 2001). "Cluster Headache -- Update on a Common Neurological Problem" (PDF). Practical Neurology 1: 42–9. Pain (Migrainous neuralgia - in 1926 ) The pain of cluster headaches is markedly greater than in other headache conditions, including severe migraines; experts have suggested that it may be the most painful condition known to medical science. Female patients have reported it as being more severe than childbirth.

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Thank you

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