HEADACHES

Prof. dr. Basjiruddin ahmad, Sp.S (K)Fakultas Kedokteran Universitas Andalas

RS. Dr. M. DjamilPadang

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Headache • In medical terminology : cephalgia• Headache is defined as pain in the head that is located above

the eyes or the ears, behind the head (occipital), or in the back of the upper neck, and has many causes

• Majority of headaches are benign and self limiting, secondary headache can life-threating conditions such as encephalitis,meningitis, tumor, cerebral hemorrhage, etc.

• Nearly universal experience• Prevalance :- 1 year periode of 90 %

- a life time of 99%• Diagnosis : Careful history, examination and diagnostic testing

Pain–sensitive structures

Similar headaches can have different cause depend on the pain-sensitive structures, include:A. Intracranial structures

– Dura near vessels– Cranial nerves V, VII, IX, X– Circle of willisy– Meningeal arteries– Large veins

B. External to the skull– Scalp and neck muscles– Cervical nervus and roots– Cutaneous nerves and skin– Mucosa of the paranasal sinuscs– Teeth– External carotid arteries

PAIN SENSITIVE CRANIAL STRUCTURES

Skin, subcutan, muscle Extracranial arteries Skull periosteum Eye, ear, nasal cavities, sinuses Intracranial venous sinuses, large

veins, pericavernous structures Basis duramater, meningeal

arteries, proximal anterior middle cerebral arteries, carotis interna arteries

Superficial temporal arteries Cranial nerves: N II, N III, N V, N IX,

N X,C1-3

Nerves SupplySplancno cranium supply by cranial nerve V, VII, IX and XNeuro cranium, structures external to the skull (including scalp and neck muscle), are supplied by nn.spinalis C1, C2, C3

Location• Cluster headaches always unilateral• 60% migraines: are unilateral, some could be spread become

bilateral• Trigeminal neuralgia: uccurs unilaterally in the second and

third trigeminal distribution• Brain tumor: bilateral or unilateral• Tension headache bilateralDuration• Migraine 4-72 hours in adults• Cluster headache 15-180 minutes• Tension type headche 30 minutes-days• Trigeminal neuralgia a few seconds < 2minutes

Headache

• Two types of headache:– Primary headache, are not associated with other diseases,

for example tension headache, migraine, cluster headache– Secondary headache, are caused by associated diseases;

may be minor or serious and life threateningTension headache is the most common type of primary headache, and more common among women than men

Classification of primary headache (international headache society 1988 modified)

1. Migrainea. Migraine without aurab. Migraine hemiplegic migrainec. Basiler migrained. Opthalmoplegic migrainee. Complications of migraine

2. Tension type headachef. Episodic tension type headache (ETTH)g. Chronic tension type headache (CTTH)

3. Cluster headache and chronic paroxismal hemicraniaa. Cluster headacheb. Chroic paroxismal hemicrania

4. Headache associated with head trauma5. Headache associated with vascular disease : infarction,

hematoma, subarachnoid hemorrhage acute arterial hypertension6. Headache associated with metabolic abnormality,

dypoxia, dialysis 7. Headache associated with intracranial disorder

a. Infection/ abscessb. Tumorc. Granulamotor disease

Classification...

8. Headache associated with us order of neck, eye, sinus, teeth

a. Cranial neuralgiab. Trigeminal neuralgiac. Glossopharyngeal neuralgia

9. Other type of headacheIce pick, cold stimulus, benign cough headache benign sex headache

10. Headache not classifable

Migraine • Migraine is a chronic condition of recurrent attacks, due to

changes in the brain and surrounding blood vessels• Pain located in the forehead, around eye, or back of head,

unilateral• Usually aggravated by daily activities, like walking upstairs etc• Nausea, vomiting, cold hands, facial pallor • Typically last from 4-72 hours and vary in frequency from daily to

fewer than 1 per year• Affects about 15% or the population (women : men = 3 : 1)• ± 80% migraineurs have other members in the family

Symptoms

• Vary from person to personFive phases often to be identified :– Prodrome : feeling “high”, irritable, depressed, funny taste of

smell– Aura : visual disturbance preceedes headacha phase, blind spots

(scotoma), flashing, colorful or lose vision on one side (hemianopia)

– Headache : on one side of the head, 30% spread on both sides• Throbbing pain, >80% nauseated, and some vomit• 70% photophobia and phonophobia

– Headache termination : pain usually goes away with sleep– Postdrome : inability to eat, fatigue, problem with concentration

may linger after pain disappeared

Phase of Acute Migrain

Causes • Exact cause is not clearly understood• Experts believe :

A combination of the expansion of blood vessels and the release of certain chemicals, which causes inflamation and pain. The chemicals dopamine and serotonine can cause blood vessels to act abnormally if they present in abnormal amounts, or if the blood vessels are unusually sensitive to them

Triggers• Certain foods : chocolate, cheese, nuts, alcohol, and MSG

(monosodium glutamate)• Stress and tension or physical stress• Birht control pills (estrogen)• Smoking • Missing a meal may bring on a headache

Associated symptoms

Before headache–60% migrainous have prodrome in hour before:– Irritability, depression, eupharia small hypertensive

During headache–Migraine: by nausea in 90%, vomiting > 50%

Foto/fobo sensitivity in 80%Nasal congestion–Cluster : ipsilateral ptosis, miosis in 30%–Dysability

After headache–Tired, drained, depression, decreased mental acuity

Migraine without aura (common migraine)• Benign periodic headache lasting several hours, without preceding

focal neurologic symptoms• Unilateral pain, nausea or vomitting, positive family history, respon

to ergotamin, scalp tenderness in 80%Migraine with aura (classic migraine)• Headache associate with characteristic premonitory sensory,

motor, or visual symptoms• Visual – scotomas or hallucinations (usually in central visual field)

paracentral scotoma expands 20 to 25 minutes

• Basilar migraine– Brainstem signs, including vertigo, dysarthria, diplopia; occur as sole

neurologic symptoms of migraine in 25%

• Hemiplegic migraine– Hemiparesis migraine may occur during prodrome; lasts 20 to 30

minutes– More severe: hemiplegia for days to weeks headache subsides– Familial from autosomal dominant

• Opthalmoplegic migraine– Attasck of periorbital pain and vomiting for 1 to 4 days. – Complete third nerve palsy follows, often including pupillary dilation,

loss of lihgt response. – May persist days to 2 months. Onset may occur in childhood

Diagnosis criteriaI. Migraine without aura

a. At least 5 attacks fulfilling b & cb. Attacks lasting 4-72 hc. During headache

- Nausea and/or vomiting- photophobi, phonofobi- Headache with 2 of tha following- Unilateral, pulsating quality- Moderate severe intensity- Aggravation by walking stairs or similar activity

II. Migraine with aura1. At least 2 attacks fulfilling b2. 3 of the following

- One or more reversible aura- Aura gradually over more than 4 minutes- No aura lasts more than 60 minutes- Headache (some with migraine without aura) follow aura with a free

interval

Management

Acute treatmentImmediate administration of full dose of agent at attack onsetMild headache : aspirin, acetaminophen. Butalbital and caffeine added if necessary. Ibuprofen, naproxen often useful. Isometheptene compounds effective for mild-to-moderate ”stress headache”

Moderate-to-severe headache: ergotamine (oral or suppository); sumatritan (oral intranasal, subcutaneous dose), Rizatriptan, zolmitriptan, naratriptan, Triptans indicated for attack frequency > 2 to 3 per month

Contra indications : Hypertension Stroke Coronary artery disease

Severe headache : dihydroergotamine (parenteral, nasal spray). Intravenous prochlorperazine, metoclopramide, dihydroergotamineChronic daily headache : amitriptyline, nortriptyline, anti depresants, valproat, topiramate

ProphylaxisDaily administration required. Effect lags 2 weeksMedications include: propanolol, amitriptiline, verapamil, valproatAdditional drug include topiramate, zonisamide.Probability of success 60% to 75% drug maybe tappered after 5 month

Tension Headache• A tension headache is the most common headache and yet it’s

not clear understood• Generally produces mild to moderate pain, in the back of neck

at the base of the skull feeling a tight band around head• Symptoms can last from 30 minutes to an entire week, or

nearly all the time (never free from headache)• Patients experience:

– Tenderness on scalp, neck and shoulder muscles– Difficulty sleeping (insomnia), fatigue, instability– Lost of appetite, difficulty concentrating

• Someimes may be severe

The causes still continue to debate exact cause are unknownResearches now believe :– Changes among certain brain chemicals – serotonine,

endorphine and numerous other chemicals – that help nerves communicate

– The process activate pain pathways to the brain and to interfere with the brain’s ability to supress the pain

– Tight muscles in the neck/scalp contribute to a headache, on the other hand, the tight muscles may be a result of these chemical changes

Causes

Muscle tension that may cause Tension Type Headache

Potential Triggers

• Stress• Depression, anxiety• Lack of sleep or changes in sleep routine• Poor posture; lack of physical activity• Working in awkward positions• Hormonal changes; menstruation, pregnancy• Overuse of headache medication

Classification of Tension Headache

1. Episodic tension-type headache (ETTH)is defined as recurrent episodes of headache(older term: tension hedache, muscle contraction headache)– Occur on fewer than 15 days a month– Lasting a few minutes to few hours– Scalp and neck muscle tenderness in addititon to head pain– Risk of developing chronic form over years

2. Chronic tension-type headache (CTTH)– Occur on 15 days a month or more for at least three months– 20% of CTTH are primary (daily from the onset) – Duration and severity are similar with ETTH, although pain is daily and

continous , and tenderness of scalp and neck

I. Pressing, tighthening nonpulsating quality• Mild or moderate intensity• Bilateral location

II. No nausea or vomiting• No aggravation by walking stairs or same /exercise• No or one of phono-photophobia

Characteristic Tension type headache

Diagnostic criteria ETTH • Characteristic I and II with :

A. At least 10 previous headache episodes number of days with such headche <180/y (<15/mo)

B. Headche lasting from 80 min-7 days

Diagnostic criteria of CTTH• Include characteristic A and B with :

Avarage headache frequent 15 days/month (180 days/year) for 6 months

Two risk of CTTH: - Analgesic rebound- Cormobidity

• Use of combination analgesics should be limited to days or 24 tablets

• SSRI (Serotinin Selective Reuptake Inhibitor) drugs may administered as a prevention (fluoxetin)

Treatment

• The goal is to relieve symptoms and prevent future headaches

• Prevention is the best treatment• If possible, remove or control headache triggers• Medications :– Over-the-counter (OTC) analgesics such aspirin,

acetaminophen, may combine with caffeine and NSAID, ibuprofen, ketoproven

– Anti depressant : amitriptilin– Non sedating muscle relaxant– Combination of bulbital and acetaminophen

Prevention • Stress management strategies• Relaxation excercises• Good posture when working, reading, activities• Enough sleep and rest• Massage of sore muscles• Lifestyle changes

Cluster headache

Episodic : most common type. One to three short-lived attacks of periorbital pain daily for 4 to 8 weeks, then pain-free interval for about 1 yearChronic: begins de novo or evolve from episodic type. Attacks similar no susteined remission.M : F = 8 : 1Onset ages 20 to 50

Clinical features– Periorbital, temporal, maxillary pain begins without

warning, peaks within 5 minutes.– Often excruciating, deep, nonfluctuating, explosive.

Strictly unilateral. Attack last 30 to 120 minutes. Frequently with ipsilateral lacrimation, red eye, nasal stuffiness, lid ptosis, nausea

TreatmentTo abort attack : oxygen inhalation (10mL/min via nonrebreathing mask), intranasal topical lidocaine, sumatriptan. To prevent further attacks during bout: prednisone, methysergide, ergotamine, verapamil

Post-concussion headache

Follow severe or trivial head injury (including head trauma without loss of consciousness). Often with vertigo, impaired memory and concentration, mood changes for months or years (post-concussion syndrome)

Brain Tumor Headache

Chief complaint in 30% of patints with brain tumor: deep, dull aching quality, moderate intensity, intermitten, worsened by exertion or change in position, associated with nausea and vomiting. Headache disturbs sleep in about 10%. Vomiting precedes headache by weeks in posterior fossa brain tumor