HEADACHES

BASJIRUDDIN A BAGIAN NEUROLOGI FK-UNAND RS. DR. M. DJAMIL PADANG

Headache

In medical terminology : cephalgia Headache is defined as pain in the head that is located above the eyes or the ears, behind the head (occipital), or in the back of the upper neck, and has many causes Majority of headaches are benign and self limiting, secondary headache can life-threating conditions such as encephalitis,meningitis, tumor, cerebral hemorrhage, etc. Nearly universal experience Prevalance :- 1 year periode of 90 % - a life time of 99% Diagnosis : Careful history, examination and diagnostic testing

Painsensitive structures
Similar headaches can have different cause depend on the pain-sensitive structures, include:

A. Intracranial structures
Dura near vessels Cranial nerves V, VII, IX, X Circle of willisy Meningeal arteries Large veins

B. External to the skull

Scalp and neck muscles Cervical nervus and roots Cutaneous nerves and skin Mucosa of the paranasal sinuscs Teeth External carotid arteries

Nerves Supply
Splancno cranium supply by cranial nerve V, VII, IX and X Neuro cranium, structures external to the skull (including scalp and neck muscle), are supplied by nn.spinalis C1, C2, C3

Headache

Location

Duration

Cluster headaches always unilateral 60% migraines: are unilateral, some could be spread become bilateral Trigeminal neuralgia: uccurs unilaterally in the second and third trigeminal distribution Brain tumor: bilateral or unilateral Tension headache bilateral Migraine 4-72 hours in adults Cluster headache 15-180 minutes Tension type headche 30 minutes-days Trigeminal neuralgia a few seconds < 2minutes

Two types of headache:

Primary headache, are not associated with other diseases, for example tension headache, migraine, cluster headache Secondary headache, are caused by associated diseases; may be minor or serious and life threatening
Tension headache is the most common type of primary headache, and more common among women than men

Classification of primary headache (international headache society 1988 modified)

1. Migraine
a. Migraine without aura b. Migraine hemiplegic migraine c. Basiler migraine d. Opthalmoplegic migraine e. Complications of migraine

2. Tension type headache

a. Episodic tension type headache (ETTH) b. Chronic tension type headache (CTTH)

Classification...

3. Cluster headache and chronic paroxismal hemicrania

a. Cluster headache b. Chroic paroxismal hemicrania

4. Headache associated with head trauma 5. Headache associated with vascular disease : 6. Headache associated with metabolic abnormality, dypoxia, dialysis 7. Headache associated with intracranial disorder
a. Infection/ abscess b. Tumor c. Granulamotor disease

infarction, hematoma, subarachnoid hemorrhage acute arterial hypertension

8. Headache associated with us order of neck, eye, sinus, teeth

a. Cranial neuralgia b. Trigeminal neuralgia c. Glossopharyngeal neuralgia

9. Other type of headache

10. Headache not classifable

Ice pick, cold stimulus, benign cough headache benign sex headache

Migraine

Migraine is a chronic condition of recurrent attacks, due to changes in the brain and surrounding blood vessels Pain located in the forehead, around eye, or back of head, unilateral Usually aggravated by daily activities, like walking upstairs etc Nausea, vomiting, cold hands, facial pallor Typically last from 4-72 hours and vary in frequency from daily to fewer than 1 per year Affects about 15% or the population (women : men = 3 : 1) 80% migraineurs have other members in the family

Symptoms

Vary from person to person Five phases often to be identified :

Prodrome : feeling high, irritable, depressed, funny taste of smell Aura : visual disturbance preceedes headacha phase, blind spots (scotoma), flashing, colorful or lose vision on one side (hemianopia) Headache : on one side of the head, 30% spread on both sides

Throbbing pain, >80% nauseated, and some vomit 70% photophobia and phonophobia

Headache termination : pain usually goes away with sleep Postdrome : inability to eat, fatigue, problem with concentration may linger after pain disappeared

Causes

Triggers

Exact cause is not clearly understood Experts believe : A combination of the expansion of blood vessels and the release of certain chemicals, which causes inflamation and pain. The chemicals dopamine and serotonine can cause blood vessels to act abnormally if they present in abnormal amounts, or if the blood vessels are unusually sensitive to them Certain foods : chocolate, cheese, nuts, alcohol, and MSG (monosodium glutamate) Stress and tension or physical stress Birht control pills (estrogen) Smoking Missing a meal may bring on a headache

Associated symptoms
Before headache 60% migrainous have prodrome in hour before: Irritability, depression, eupharia small hypertensive During headache Migraine: by nausea in 90%, vomiting > 50% Foto/fobo sensitivity in 80% Nasal congestion Cluster : ipsilateral ptosis, miosis in 30% Dysability After headache Tired, drained, depression, decreased mental acuity

Migraine without aura (common migraine)

Migraine with aura (classic migraine)

Benign periodic headache lasting several hours, without preceding focal neurologic symptoms Unilateral pain, nausea or vomitting, positive family history, respon to ergotamin, scalp tenderness in 80%

Headache associate with characteristic premonitory sensory, motor, or visual symptoms Visual scotomas or hallucinations (usually in central visual field) paracentral scotoma expands 20 to 25 minutes

Basilar migraine
Brainstem signs, including vertigo, dysarthria, diplopia; occur as sole neurologic symptoms of migraine in 25%

Hemiplegic migraine
Hemiparesis migraine may occur during prodrome; lasts 20 to 30 minutes More severe: hemiplegia for days to weeks headache subsides Familial from autosomal dominant

Opthalmoplegic migraine
Attasck of periorbital pain and vomiting for 1 to 4 days. Complete third nerve palsy follows, often including pupillary dilation, loss of lihgt response. May persist days to 2 months. Onset may occur in childhood

Diagnosis criteria I. Migraine without aura

a. At least 5 attacks fulfilling b & c b. Attacks lasting 4-72 h c. During headache

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II.

Migraine with aura

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Nausea and/or vomiting photophobi, phonofobi Headache with 2 of tha following Unilateral, pulsating quality Moderate severe intensity Aggravation by walking stairs or similar activity

1. At least 2 attacks fulfilling b 2. 3 of the following

One or more reversible aura Aura gradually over more than 4 minutes No aura lasts more than 60 minutes Headache (some with migraine without aura) follow aura with a free interval

Management
Acute treatment
Immediate administration of full dose of agent at attack onset
Mild headache : aspirin, acetaminophen. Butalbital and caffeine added if necessary. Ibuprofen, naproxen often useful. Isometheptene compounds effective for mild-to-moderate stress headache

Moderate-to-severe headache: ergotamine (oral or suppository); sumatritan (oral intranasal, subcutaneous dose), Rizatriptan, zolmitriptan, naratriptan, Triptans indicated for attack frequency > 2 to 3 per month Contra indications :
Hypertension Stroke Coronary artery disease

Severe headache : dihydroergotamine (parenteral, nasal spray). Intravenous prochlorperazine, metoclopramide, dihydroergotamine Chronic daily headache : amitriptyline, nortriptyline, anti depresants, valproat, topiramate

Prophylaxis Daily administration required. Effect lags 2 weeks Medications include: propanolol, amitriptiline, verapamil, valproat Additional drug include topiramate, zonisamide. Probability of success 60% to 75% drug maybe tappered after 5 month

Tension Headache

A tension headache is the most common headache and yet its not clear understood Generally produces mild to moderate pain, in the back of neck at the base of the skull feeling a tight band around head Symptoms can last from 30 minutes to an entire week, or nearly all the time (never free from headache) Patients experience:
Tenderness on scalp, neck and shoulder muscles Difficulty sleeping (insomnia), fatigue, instability Lost of appetite, difficulty concentrating

Someimes may be severe

Causes
The causes still continue to debate exact cause are unknown Researches now believe :
Changes among certain brain chemicals serotonine, endorphine and numerous other chemicals that help nerves communicate The process activate pain pathways to the brain and to interfere with the brains ability to supress the pain Tight muscles in the neck/scalp contribute to a headache, on the other hand, the tight muscles may be a result of these chemical changes

Potential Triggers
Stress Depression, anxiety Lack of sleep or changes in sleep routine Poor posture; lack of physical activity Working in awkward positions Hormonal changes; menstruation, pregnancy Overuse of headache medication

Classification of Tension Headache

1.

Episodic tension-type headache (ETTH) is defined as recurrent episodes of headache

(older term: tension hedache, muscle contraction headache) Occur on fewer than 15 days a month Lasting a few minutes to few hours Scalp and neck muscle tenderness in addititon to head pain Risk of developing chronic form over years

2.

Chronic tension-type headache (CTTH)

Occur on 15 days a month or more for at least three months 20% of CTTH are primary (daily from the onset) Duration and severity are similar with ETTH, although pain is daily and continous , and tenderness of scalp and neck

Characteristic Tension type headache

I. Pressing, tighthening nonpulsating quality
Mild or moderate intensity Bilateral location

II. No nausea or vomiting

No aggravation by walking stairs or same /exercise No or one of phono-photophobia

Diagnostic criteria ETTH

Characteristic I and II with : A. At least 10 previous headache episodes number of days with such headche <180/y (<15/mo) B. Headche lasting from 80 min-7 days Include characteristic A and B with : Avarage headache frequent 15 days/month (180 days/year) for 6 months

Diagnostic criteria of CTTH

Two risk of CTTH: - Analgesic rebound - Cormobidity Use of combination analgesics should be limited to days or 24 tablets SSRI (Serotinin Selective Reuptake Inhibitor) drugs may administered as a prevention (fluoxetin)

Treatment
The goal is to relieve symptoms and prevent future headaches Prevention is the best treatment If possible, remove or control headache triggers Medications :

Over-the-counter (OTC) analgesics such aspirin, acetaminophen, may combine with caffeine and NSAID, ibuprofen, ketoproven Anti depressant : amitriptilin Non sedating muscle relaxant Combination of bulbital and acetaminophen

Prevention
Stress management strategies Relaxation excercises Good posture when working, reading, activities Enough sleep and rest Massage of sore muscles Lifestyle changes

Cluster headache
Episodic : most common type. One to three short-lived attacks of periorbital pain daily for 4 to 8 weeks, then pain-free interval for about 1 year Chronic: begins de novo or evolve from episodic type. Attacks similar no susteined remission. M:F=8:1 Onset ages 20 to 50

Clinical features
Periorbital, temporal, maxillary pain begins without warning, peaks within 5 minutes. Often excruciating, deep, nonfluctuating, explosive. Strictly unilateral. Attack last 30 to 120 minutes. Frequently with ipsilateral lacrimation, red eye, nasal stuffiness, lid ptosis, nausea

Treatment
To abort attack : oxygen inhalation (10mL/min via nonrebreathing mask), intranasal topical lidocaine, sumatriptan. To prevent further attacks during bout: prednisone, methysergide, ergotamine, verapamil

Post-concussion headache
Follow severe or trivial head injury (including head trauma without loss of consciousness). Often with vertigo, impaired memory and concentration, mood changes for months or years (post-concussion syndrome)

Brain Tumor Headache

Chief complaint in 30% of patints with brain tumor: deep, dull aching quality, moderate intensity, intermitten, worsened by exertion or change in position, associated with nausea and vomiting. Headache disturbs sleep in about 10%. Vomiting precedes headache by weeks in posterior fossa brain tumor

References

Adams RD. Principles of neurology 6th ed Mc Graw Hill 1997 Harsono, Buku Ajar Neurologi, Bab II Harsono, Kapita selekta neurologi, Bab II Mazzoni.P.Merritts`s Neurology Handbook. 2nd ed Dresden. Lippincott William & Wilkins. 2007 Evans RW. Hanbook of headache. Philadelphia Lipincott William & Wilkins, 1999 Headache wikipedia Mayo clinic com

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