Approach to patient with Headache

Introduction pain cranium faceneck Headache

Sensitive and Insensitive intracranial structures

Primary and Secondary Headaches Headache disorders primarysecondary Why is it primary? primary headaches do not have an underlying structural cause

Primary and Secondary Headaches all the primary headache disorders can be simulated by secondary conditions Note :

Primary Headaches  Migraine  Tension-type headache  Cluster headache.  Trigeminal cephalalgias. Primary stabbing headache Primary cough headache Primary exertional headache Primary headache associated with sexual activity. Hypnic headache Primary thunderclap headache daily-persistent headache

Secondary Headaches  attributed to head / neck trauma.  attributed to cranial or cervical vascular disorder.  attributed to nonvascular intracranial disorder.  attributed to substance or its withdrawal  attributed to infection.  attributed to disorder of cranium, neck,eyes, ears, nose, sinuses, teeth, mouth..  attributed to psychiatric disorder.

Diagnosis diagnosis History appropriate investigations neurological and general examinations

1- History  The gold standard for diagnosis and management of headache is a careful interview and neurological and general medical examinations.  In the vast majority of patients with headache, the neurological and general examinations will be normal, so the diagnosis is based entirely on the history,

What should you ask the patient ?? Before you start asking the patient give him 2 minutes to describe his symptoms..

The first question is ? How many types of headache do you have ?

Temporal profile Onset of headache Episodic/chronic.. frequency&periodisity Time to reach max intensity Duration of pain Time of day Location & nature location quality & severity Premonitory symp, aura Accompanying symp Affecting factors precipitatingaggravatingmitigating Family history of headache Prior treatment

Precipitating Factors what factors trigger your headaches?  bright light, weather changes( migraine)  mensturation  Alcohol  drugs  certain foods and food additives  caffeine withdrawal,  sleeping, stress  perfume and smoke.  If bending, coughing, or Valsalva maneuver( intracranial lesion?, posterior fossa?,

Precipitating Factors  Exertional headache and headache associated with sexual activity :  primary headache disorder ?  SAH and arterial dissection?  intermittent headaches worsened by standing (CSF) leak.  Glossophyrengeal neuralgia …

2- Examination  Vital signs, (Bp, pulse).  Extremely high blood pressure can cause headache.  If there is a fever, temperature should be measured.  A neurological examination, is essential.  The skull should be palpated for lumps and local tenderness.

2-Examination  The area over an infected sinus may be tender  Thickened, tender, irregular temporal arteries with a reduced pulse suggest GCA.  The cervical spine also should be tested for tenderness, Nuchal rigidity.

3- Diagnostic Testing  history, with the neurological and physical examinations, are all needed for diagnosis, especially in the patient with long-standing headaches.(migrane, cluster, tension type headache)  In some situations, the diagnosis is uncertain, and additional diagnostic testing should be considered. (when there is worrisome headache “warning flags”)

Diagnostic Testing Red Flags ■ Head or neck injury. ■ New onset or new type or worsening pattern of existing headache. ■ New level of pain (e.g., worst ever). ■ Triggered by Valsalva maneuver or cough. ■ Triggered by exertion. ■ Triggered by sexual activity. ■ Headache during pregnancy or puerperium. ■ Age > 50 years.

Diagnostic Testing Red Flags ■ Neurological signs or symptoms : Seizures / Confusion / Impaired alertness / Weakness. ■ Papilledema. ■ Systemic illness : Fever / Nuchal rigidity / Weight loss /. ■ Secondary risk factors : Cancer / Immunocompromised / HIV / … ■ Recent travel : Domestic / Foreign.

Diagnostic Testing Yellow Flags ■ Wakes patient from sleep at night. ■ New onset side-locked headaches. ■ Postural headaches.

Neuroimaging and Other Imaging Studies CT Preferred  Fractures (calvarium).  Acute hemorrhage (subarachnoid, intracerebral).  Paranasal sinus and mastoid air cell disease.

Neuroimaging and Other Imaging Studies MRI Preferred  Vascular disease:  Cerebral infarction  Venous infarction  Neoplastic disease:  Primary and secondary brain tumors (especially in posterior fossa).  Skull base tumors  Meningeal carcinomatosis and lymphomatosis  Pituitary tumors

Neuroimaging and Other Imaging Studies MRI Preferred  Infections:  brain abscess.  Meningitis.  Encephalitis.  Other:  Chiari malformation.  Cerebrospinal fluid hypotension  Pituitary apoplexy

Neuroimaging and Other Imaging Studies Draw between MRI and CT  MR angiography/CT angiography:  Vasculitis (large and medium sized vessels)  Intracranial aneurysms  Carotid and vertebral artery dissections  MR venography/CT venography:  Cerebral venous thrombosis.

Neuroimaging and Other Imaging Studies Plain Radiographs of the Skull, Sinuses, and Cervical Spine  unusual bony abnormality found on physical examination  in the pediatric population.  degenerative disk and joint disease of the upper cervical spine.  RA and ankylosing spondylitis ?.

Neuroimaging and Other Imaging Studies  exclude fractures in patients with a history of head and neck injury. Myelography with Computed Tomography and Radioisotope Studies.

Cerebrospinal Fluid Tests diagnose or exclude meningitis, encephalitis, SAH.  ↑ or ↓ ICP by measurement of the opening CSF pressure.  diagnosis of “headache and neurological deficits with CSF lymphocytosis” (HaNDL)

General Medical Tests  CBC : infection?  ESR : ↑ GCA?  Carboxyheamoglobin: heating seasons?  TSH : hypothyrodism?