headache Headache is one of the commonest neurological

headache § Headache is one of the commonest neurological complain reported at neurology clinic §

path physiology Intracranial pain sensitive structures include: the arteries of the circules of willis &the first few centimeters of their median sized branches Meningeal arteries Large veins &dural venous sinuses Extra cranial sensitive structures: external carotid arteires, scalp , neck muscle , skin & cutaneous nerves, cervical nerve &nerve roots, mucosa of the sinus &teeth. .

Case history § 25 y old f with h/o : ER h/o sever headache , diffuse , dull in nature , not relived by analgesia, aggrevated by cough , sneezing. § Assosiated with vomiting § No other neurological symptoms. § She gave h/o of chronic infrequent headache , which tension type and less sever, relieved by analgesia § She is single § Recently She was following with dermatology doctor and he gave her tablets for facial peeling

O/E § § Neurological exam : HF: N Speech : normal Cranial nerves: fundoscopic exam: papilledema § Motor, sensory, coordination : normal

§ Is this headache serious?

headache § Primary (benign) secondary § e. g(Migraine, tension, cluster) § § § serious brain meninges parenchyma vacsular CSF systemic referred HPT ear, teeth anemia eye, sinus

Secondary causes (serious) § § Structural causes Meninges: meningitis parenchyma : encephalitis , abscess, tumor Vascular: hemorrhage, venous thrombosis, giant cell arterities § Csf: increase CSF pressure (hydrocephalus , pseudotumor cerebri) , decrease CSF pressure…leak

§ Careful history and examination should be done to differentiate between benign and serious headache

Age § Migraine headache: child hood or early adulthood § Giant cell arteritis: >50 y § New onset headache in elderly should be always a concern

Onset § Headache of many years duration &with little changes is almost always of benign origin § New onset headache in old age or increasingly sever headache …. serious headache. . § Hyperacute : SAH

periodicity: § episodic headache is benign § Migraine , Cluster headache § a daily constant headache. . tension type

duration § § § Migraine: 4 -72 h Cluster: 1/2 -2 h Tension headache : build up over hours lasts days to years

Location § unilateral headache: migraine, cluster, temporal arterities. § Tension headache : generalized , frontal or posterior cervical region § Carotid dissection commonly present with neck, face, and head pain usually ipsilateral to the dissection § Local pain : superfacial structures

Nature § § § Nature: throbbing: vascular Tension : fullness, tightness, pressure like

aura, & associated symptoms § migraine: aura; focal cerebral symptoms associated with lasts from 20 -30 min, precedes the headache § Sensory, motor, autonomic, . . § Cluster headache: ptosis, lacrimation, conjuctival , nasal congestion § Headcahe +fever …. . infection § Transient visual obscuration, diplopia, tinnitus …increase intracranial pressure

aura, & associated symptoms § Jaw clawdication: temporal arteritis § Headache: progressive+ central nervous symptoms is suggestive …structural brain lesion

Aggravating & relieving § § § Aggravating Cough, straining……intracranial pressure Activity. , stress…. . migraine, tension type Sitting: CSF hypotension Relieving: Rest……. migraine, tension

Drug history § Oral contraceptive… Cerebral vein thrombosis, migraine § Steroid withdrawal § Retin A tablets § Warfarin : Hge pseudotumor cerebri

§ Postpartum : cerebral venous thrombosis § Recurrent abortion

FH § migraine

exam § § § v/s: fever , BP General: sinus tenderness Eye , throat , ear exam

exam § Normal exam: benign headache § Papilledema: increased intracranial pressure § Focal neurological finding……serious § Complicated migraine…. neurological signs § Horner syndrome: cluster headache § Scalp tenderness, pulsless: temporal arteritis

Is this headache serious? § § § § Characteristics of headache with serious underlying pathology History : Explosive onset and severe at onset No similar headaches in the past you have a constant headache, which is gradually getting worse; Altered mental status Age over 50 Immunosuppression § § § Physical examination : Neurologic abnormalities Decreased level of consciousness Meningismus Papilledema

Work up § If history and exam is suggestive of serious headache § Brain image: CT brain, mri brain § If suspect cerebral vein throbosis. . CT venogram , MRV § § if fever or ? SAH …LP

Go back to the case

Case history § 25 y old f with h/o : ER h/o sever headache , diffuse , dull in nature , not relived by analgesia, aggrevated by cough , sneezing. § Assosiated with vomiting § No other neurological symptoms. § She gave h/o of chronic infrequent headache , which tension type and less sever, relieved by analgesia § She is single § Recently She was following with dermatology doctor and he gave her tablets for facial peeling

O/E § § Neurological exam : HF: N Speech : normal Cranial nerves: fundoscopic exam: papilledema § Motor, sensory, coordination : normal

Work up § § CT brain : normal MRI brain: N MRV: N LP: increased CSF pressure, protein, glu, cell count were normal

§ Pseudo tumor cerebri § ( Idiopathic Intracranial Hypertension )

Home message Careful history and exam including (opthalmoscopic) exam is the key to differentiate benign from serious headache.