1. Dr sadik al ghazawi Associated professer Neurologist Mrcp,frcp uk
Headache
Dr sadik al ghazawi
Associated professer
Neurologist
Mrcp,frcp uk

2. Accounts for 1% to 2% of emergency department evaluations and up to 4% of medical office visits
Headache is caused by traction, displacement, inflammation, or distention of the pain-sensitive structures in the head or neck

3. Intracranial Pain-Sensitive Structures
Venous sinuses
Anterior and middle meningeal arteries
Dura at the base of the skull
Trigeminal (V), glossopharyngeal (IX), and vagus (X) nerves
Proximal portions of the internal carotid artery and its branches near the circle of Willis
Brainstem periaqueductal gray matter
Sensory nuclei of the thalamus

4. Venous sinuses

5. periaqueductal gray matter

7. Causes of headache Primary Migraine Tension-type Cluster
Paroxysmal hemicrania
Trigeminal neuralgia
Chronic daily headache
Secondary
Medication overuse (rebound)
head/neck trauma
Vascular disorder – SAH, AVM, vasculitis, CSVT
High ICP / Low ICP
Tumor
Infection
CNS
Other infections

8. Red Flags in Hx

9. Red Flags in Hx “Worst HA of my life” New onset HA
Change in character of headache
Awakens him from sleep
Associated with focal symptoms or fever
Worsening with bending, laying down, coughing or sneezing
Immunocompromised
h/o cancer

11. Migraine Prevalence 12% More than 90% before age 40
begins with visual or other neurologic symptoms in approximately 15% to 20% of patients (migraine with aura, or classic migraine)
In most cases no aura occurs (migraine without aura, or common migraine

12. Diagnostic Criteria:
A. At least 5 attacks fulfilling criteria B through D
B. Headache attacks lasting 4 to 72 hours (untreated or unsuccessfully treated)
C. Headache has at least two of the following characteristics:
Unilateral location
Pulsating quality
Moderate or severe pain intensity
Aggravation by or causing avoidance of routine physical activity (eg, walking or climbing stairs)
D. During headache at least one of the following:
1. Nausea and/or vomiting
2. Photophobia and phonophobia
E. Not attributed to another disorder

13. Management Prophylactic propranolol(inderal) Abortive, analgesia
Triptans

14. Tension headache A. At least 10 episodes
Fulfilling criteria B through D listed below
B. Headache lasting from 30 minutes to 7 days
C. Headache has at least two of the following pain characteristics:
1. Bilateral location
2. Mild or moderate intensity (may inhibit but does not prohibit activity)
3. Pressing/tightening (non-pulsating) quality
4. No aggravation while climbing stairs or similar routine physical activity

15. D. Both of the following: 1
D. Both of the following: 1. No nausea or vomiting (anorexia may still occur) 2. No more than one of photophobia and phonophobia
E. Not attributed to another disorder

16. Cluster HA A. At least five attacks fulfilling criteria B through D
B. Severe or very severe unilateral orbital, supraorbital, and/or temporal pain lasting 15 to 180 minutes if untreated
C. Headache is accompanied by at least one of the following:
1. Ipsilateral conjunctival injection and/or lacrimation
2. Ipsilateral nasal congestion and/or rhinorrhea
3. Ipsilateral eyelid edema
4. Ipsilateral forehead and facial sweating
5. Ipsilateral miosis and/or ptosis
6. A sense of restlessness or agitation

17. D. Attacks have a frequency from one every other day to eight per day
E. Not attributed to another disorder

18. Trigeminal neuralgia (tic douloureux)
In many instances, the trigeminal (V) nerve roots are close to a vascular structure, and microvascular compression followed by demyelination of the nerve is believed to cause the disorder.
Second (V2) and third (V3) divisions of the trigeminal (V) nerve
Lightning-like momentary (>1 second to approximately 2 minutes)
Trigger zones about the cheek, nose, or mouth by touch, cold, wind, talking, or chewing can precipitate the pain.
Young pts, bilateral symptoms or abn exam
r/o MS and brainstem tumors

20. Medication-overuse HA
A. Headache > or = 15 d/mo B. Regular overuse for >3 months of > or = 1 acute/symptomatic treatment drugs:
1. Ergotamine, triptans, opioids, or combination analgesic medications on > or = 10 d/mo on a regular basis for >3 months
2. Simple analgesics or any combination of ergotamine, triptans, or analgesics opioids on > or = 15 d/mo on a regular basis for >3 months without overuse of any single class alone
C. Headache developed or markedly worsened during medication overuse