Headache ( Cephalgia)
• Headache is actually a
symptom rather than a
disease entity;
• It may indicate organic
disease (neurologic or
other disease), a stress • Headache is a non-specific
response, vasodilation symptom, which means that it
(migraine), skeletal muscle has many possible causes.
tension (tension headache),
or a combination of • The membrane and blood
factors. vessels of the brain are very
pain sensitive
Primary headache (99% +)
• It is the one for which no organic cause can be
identified.
• These types of headache include migraine, tension-
type, and cluster headaches.
Secondary headache (<1%)
• It is a symptom associated with an organic cause,
such as a brain tumor or an aneurysm.
• Most headaches do not indicate serious disease,
although persistent headaches require further
investigation.
• Serious disorders related to headache include
brain tumors, subarachnoid hemorrhage, stroke,
severe hypertension, meningitis, and head
injuries.
Migraine
• It is a symptom complex characterized by periodic
and recurrent attacks of severe headache.
• The typical time of onset is puberty, and the
incidence is highest in adults 20 to 35 years of age.
• Most patients have migraine without an aura.
Migraine (“half-head”)
• Frequency : 1-2/year- 2-3/week
• Pain moderate: Severe pulsating, throbbing
• Duration: 4 hrs - 3 days
• Location usually one sided (but side can swap
between attacks)
• Symptoms:
• Aura,
• Nausea & vomiting,
• Sensitive to light, sound, smells
Typical migraine patient
• Onset often as child / teenager / young adult
• But can start at any age
• 2-3 x more common in women than men
• Typical patient : young woman (15% of all young
women)
What happens during a migraine?
Cause
• Cause unknown but strongly inherited
• A lower threshold to spontaneously produce
symptoms as if the head and brain had been injured
• Many effective treatments
• Primarily a vascular disturbance that occurs more
commonly in women and has a strong familial
tendency.
Pathophysiology
Abnormal metabolism of serotonin, a vasoactive
neurotransmitter found in platelets and cells of the
brain, plays a major role.
The headache is preceded by a rise in plasma
serotonin, which dilates the cerebral vessels.
The exact mechanism of pain in migraine is not
completely understood but is thought to be related to
the cranial blood vessels, the innervation of the
vessels, and the reflex connections in the brain stem.
Pathophysiology…….
• It is the most common cause of vascular headache.
• It approximately affects 15% of women and 6% of
men.
• It usually begins in childhood or young adult life.
Etiology
The cause of migraine is often unknown, but several
common precipitants have been observed.
Family history of migraine present in nearly 2/3 of
patients.
Environmental, dietary and psychological factors.
Emotional stress, depression.
Etiology……
Altered sleep pattern or sleep deprivation.
Menses, oral contraceptives.
Alcohol intake: wine
Caffeine withdrawal.
Various food staffs (e.g. spices, chocolates, nuts,
cheese, citrus, meats containing nitrates).
Food additives : monosodium glutamate
Clinical Manifestations (migraine)
• The migraine with aura can be divided into four
phases:
1. Prodrome
2. Aura
3. The headache and
4. Recovery (headache termination and
postdrome).
Prodrome
• It is experienced by 60% of patients with symptoms
that occur hours to days before a migraine headache.
– Symptoms include depression, irritability, feeling
cold, food cravings, anorexia, change in activity
level, increased urination, diarrhea, or
constipation.
– Patients usually experience the same prodrome
with each migraine headache.
Aura Phase
• Aura occurs in up to 31% of patients who have
migraines.
• The aura usually lasts less than an hour and may provide
enough time for the patient to take the prescribed
medication to avert a full-blown attack.
• Characterized by focal neurologic symptoms: Visual
disturbances (i.e, light flashes and bright spots) are
common and may be hemianopic (affecting only half of
the visual field).
• Other symptoms that may follow include numbness and
tingling of the lips, face, or hands; mild confusion; slight
weakness of an extremity; drowsiness; and dizziness.
Headache Phase
• As vasodilation and a throbbing headache (unilateral
in 60% of patients) intensifies over several hours.
• This headache is severe and incapacitating and is often
associated with photophobia, nausea, and vomiting.
• Its duration varies, ranging from 4 to 72 hours.
Recovery Phase
• In the recovery phase, the pain gradually subsides.
• Muscle contraction in the neck and scalp is common,
with associated muscle ache and localized tenderness,
exhaustion, and mood changes
Tension headache
• It tend to be more chronic than severe and are
probably the most common type of headache
• Characterized by a steady, constant feeling of
pressure that usually begins in the forehead, temple,
or back of the neck.
• It is often bandlike or may be described as “a weight
on top of my head.”
Tension headache….
• Frequency chronic often daily
• Pain: mild-moderate pressure, tightness
• Duration 30 mins - 7 days
• Location both sides, whole head, and neck
• Symptoms: no light / sound sensitivity, no aura
• Now thought to be due to increased brain
sensitivity to normal sensory inputs
Cluster headache
• It is a severe form of vascular headache
• They are seen five times more frequently in men than
women .
• The pathophysiology of cluster headache is not fully
understood.
• One theory is that it is due to dilation of orbital and near
by extracranial arteries.
• There may be immune vasculitis in which immune
complexes are deposited within the walls of affected
blood vessels, producing vascular injury and
inflammation.
Cluster headache.…..
• Are unilateral and come in clusters of one to eight
daily, with excruciating pain localized to the eye and
orbit and radiating to the facial and temporal regions.
• The pain is accompanied by watering of the eye and
nasal congestion.
• Each attack lasts 30 to 90 minutes
• The headache is often described as penetrating and
steady.
Cluster Headache…..
• Frequency clusters – every time each year or season; then
free
• Pain: excruciating
penetrating, boring
continuous, non-throbbing
• Duration: 15mins-3 hrs; same clock time each day
(2am); several episodes / day
• Location: ALWAYS the same side
• Symptoms: watering eyes
nasal stuffiness, runny nose
red eye, swollen eyelids
sweating
• Typical patient : middle aged male smoker
Cluster Headache……..
Assessment and Diagnostic Evaluation
• The health history
• Characterize the headache: the quality, location,
duration, time course, the conditions that
produce, exacerbate or relieve.
• Look also for associated symptoms, medication
history and psychiatric history.
Physical Examination
• Head and neck examination scalp tenderness, sinus
tenderness, examination of the oral cavity and tempo-
mandibular joint.
• Ophthalmologic evaluation including fundoscopic
examination pupillary size, corneal clouding.
• Systematic evaluation of other systems (glands, chest,
CVS, abdomen, GUS, MSS ,and integumentary
system).
Physical Examination……
• Neurological examination including change in
mental status, focal neurological deficit, neck
stiffness and other meningeal signs.
• CT scan, cerebral angiography, or MRI may be used
to detect underlying causes, such as tumor or
aneurysm.
Medical Management
• Therapy for migraine headache is divided into
abortive (symptomatic) and preventive approaches.
• The abortive approach, best employed in patients
who suffer less frequent attacks, is aimed at relieving
or limiting a headache at the onset or while it is in
progress.
• The preventive approach is used in patients who
experience more frequent attacks at regular or
predictable intervals and may have medical
conditions that preclude the use of abortive therapies.
Medical Management…..
• Ergotamine acts on smooth muscle, causing
prolonged constriction of the cranial blood vessels.
• It is available in oral, intranasal, and subcutaneous
preparations and is effective for the treatment of acute
migraine and cluster.
• Additional strategies may include the use of analgesic
agents, antidepressant medications,and muscle
relaxants.
• Patient education about appropriate changes in
lifestyle to avoid triggers.
Medical Management…..
• Regular sleep, meals, exercise, and avoidance of
dietary triggers may be helpful in avoiding headaches .
• The patient with tension headaches needs teaching and
reassurance that the headache is not due to a brain
tumor.
• Stress reduction techniques, such as exercise
programs, and meditation, are examples of
nonpharmacologic therapies that may prove helpful.
