Headache

=Reading= Gelb, chapter 12, pp 279-297

=Background= =Approach=

> Emergency?
Qualitatively different? stiff neck? new focal neurolgial abnormality? worst headache of my life? > Maybe, maybe not. Determine if qualitatively different from other headaches. if not, don't worry if qualitatively different, conside emergency need to r/o subarachnoid hemorrhage (SAH) can't be clinically distinguished from meningitis pain usually more abrupt, fever more common...but can't r/o unless pt afebrile, normal cardiovascular, repsiartory, and mental status, adminster IV antibiotis...2 million units penicillin or 2g cefotaxime or ceftriaxone glucocorticoids useful in children wtih h. influenze meningitis lumbar puncure fr meningitis CT scan quickly > still miss 10% of SAH > normal CT scan necessitates lumbar puncure

lumbar puncture bacterial: more than 5 WBC per uliter-> bacterial lymphocytes, normal glucose --> iral (but usually still continue IV antibiotics) SAH: RBCs in CSF need to spin down CSF immediately to differentiate old blood (*with xanthohromia) versus blood from puncure process

if SAH is likely, need a neurosurgeon

> Which syndrome?
character of pain other synmptoms time course provking, alleviating factors motion sickness family hx

character: throbbing, pulsing, burning, squeezing, lightinign, bursting, pressure? combo? unitlateral/bilateral? frontal/temporal/parietal/occipatal/facial/nucah? more than 1 typpe?

other symptooms: nausea, vomiting, photophobia, phonophonia, visual disturbances, numbess, weakness, dizziness, speach problems, confusion? nasal congestion, rhinoorrhea, unilateral tearing? conjunctitis? ptosis? pupillary defect?

which symptoms come first? progression? pain maximal at onset or hiuild? how many minutes or hours last? resolve suddenly how frequent occur? any time of day? in clusters? first onset? chanage in character over time?

foods? chocolate/caffeine, cheese, MSG, glutamate, processed meats, pickled alchohol? position of pt head? emotional stress? change in medication....birth control pills mentrusal cycle

=Primary headaches= systemic versus neurlogical cause if etiology unclear after history, exam... > focal abnormality or recent onset necessitate radiological evaluation

> Migraine, tension
trigeminal factors active fibers that innervate meningeal and parenchymal blood vessels. The periascular release of neuropeptides creates an inflammatory response. There is also a spreading cortical depression

==> Temporal Arteritis head pain..dull, superficial, superimposed lancinating pains unilateral or bilateral often temporal, sometimes elsewhere often temporal arteryh tenderness, jaw claudication 40-50% also have polymyalgia hrheymatica--pain, stiffness of limbs focal deicits or generalized mental status changes 50% untreat patients -> bilateral blindness check ESR on all pts older than 50 with recent onset headache ESR elevated in 95% biopsy for confirmation... > false negatives from focal involvemetn treatment high-dose prednsone

> Cluster
distinctive time course may go years, then have cluster daily headaches clusters usally last 4-8 weeks, occur one or twice a year usually last 30 min to 2 hours explosive onst cannot sit or stand cill...hit head against wall 'could set the clock by them' awake from REM sleep unilateral almost always same side associated with ipsilateral lacrimation, red eye, nasal congestion, rhinorreal, partial Horner's syndrome 6x prevalence men vs women abortants: 100 O2 for 10-14 min intranasal egotamine intranasal lidocaine, ipsilateral IV dihydroergotamine sucuaneous sumatriptan

medications: prednisone 80mg per day, then taper other alts: verapaminl ergotamine valproic acid lithium arbonate methysergide should be tapered after headache free 2 weeks frequent clusterss may need lightium or verapamil for prophylaxis surgial intervention for those 10% pts who are refractory to pharamolcoial interventions

> Trigeminal neuraliga
AKA, //tic douloureux// paroxysmal 'electric shock' pain maxilla or mandible lasts 1 second trains 5-30s sometimes triggerd by //trigger zone// on face alos trigged by cold wind, brshing teeth, chewing does not wake from sleep often superimposed dull ache usually benign idopathic or compression of trigeminal root other lesions of 5th nerve common in MS usually onset after age 50 younger onset may imply MS MRI should be done if new onset, change in character, or uner age 50, or focal abnormalities can result from dental probelms initial treatment carbamazepine (Tegretol) also baclofin,gababpentin, lamotrigine, phenytoin (*dilantin), amitryptaline(elavil_, valproic acid (Depakote), clonazepam2 surgical options: microvascular decompression of nerve root percutaneous lesion of ganglia or root with radiofrequency radiation or glycerol injection > S/E: anesthsia dolorosa numbness, parestheia

> Glossopharyngeal neualgia
oropharynx to ear swallowing yawning, sneezing, coughing, cold liquids, toching ears can trigger awakesns pts from sleep sometimes syncope treatment as trigeminal

> Chronic paroxysmal hemicrania
short duration (minutes) frequent recurrence (averrage 14/day) no nocturnal predominance happen daily 5x more common in women responsive to indomethacin

> Atypical facial pain
catch-all category...qualties of others

=Secondary headaches=

> TMJ disease
can be referred

> posttraumatic syndrome
hard to document may last years

=Goals=

2. Know when a headache is an emergency: subarachnoid hemorrhage, meningitis, temproal arteritis
==3. Cnow clinical features of tenstion/migrain, cluster, trigeminal neuralgia, idiopathic intracranial hypertension, spontaneous intracranial hypotension, cerebral venous thrombosis, arterial dissection==

4. Pathophysiology of headache
>> pain-senstiiteve head sturctures; pain pathways; neurogenic einflammation; spreading depression; serotonin

6. Management
>> abortie and prohlactic agents, medications: NSAIDs, analgesics, triptans, ergots, beta blockers, CCBs, TCAs, anti-epileptic drugs