Headaches

Dr. Mohammad Reza Najafi Professor of Neurology

دکترمحمدرضانجفیدکترمحمدرضانجفی

مغزواعصاب مغزواعصاب استاد استاد

Introduction

Nearly everyone is subject to headache from time to time;moreover, 40% of all people have severe headaches annually.

The brain mechanism that generates headaches isactivated by many factors.

Genetic factors probably augment the system, so that some people are susceptible tomore frequent or more severe head pain.

Headache is usually a benign symptom and only occasionallyis a manifestation of a serious illness, such asbrain tumor, aneurysmal rupture or giant cell arteritis.

The first issue to resolve in the care of a patient withheadache is to differentiate benign and more ominouscauses.

Painful state characteristicsPainful state characteristics1-1- Quality Quality 2-2- Severity Severity3-3- Location Location4-4- Duration Duration5-5- Time course Time course6-6- Intensity Intensity7-7- Mode of onset Mode of onset8-8- Time - intensity curve Time - intensity curve9-9- Conditions that produce , Conditions that produce ,

exacerebation, relieve exacerebation, relieve 10-10- personality of patients personality of patients

1-1- Quality Quality 2-2- Severity Severity3-3- Location Location4-4- Duration Duration5-5- Time course Time course6-6- Intensity Intensity7-7- Mode of onset Mode of onset8-8- Time - intensity curve Time - intensity curve9-9- Conditions that produce , Conditions that produce ,

exacerebation, relieve exacerebation, relieve 10-10- personality of patients personality of patients

IHS Classification ofHeadache

Part I: The Primary Headaches

1. Migraine 2. Tension-type headache 3. Cluster headache and other trigeminal

autonomic cephalalgias

4. Other primary headaches

Part II: The Secondary Headaches

5. Headache attributed to head and/or 5. Headache attributed to head and/or neck neck trauma trauma

6. Headache attributed to cranial or 6. Headache attributed to cranial or cervical cervical vascularvascular disorder disorder

7. Headache attributed to 7. Headache attributed to non-vascular non-vascular intracranial disorder intracranial disorder

8. Headache attributed to a 8. Headache attributed to a substance or substance or its withdrawal its withdrawal

9. Headache attributed to 9. Headache attributed to infection infection

10. Headache attributed to disorder of homoeostasis

11. Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures

12. Headache attributed to psychiatric 12. Headache attributed to psychiatric disorderdisorder

Part III: Cranial Neuralgias Central and Primary Facial Pain and Other Headaches

13. Cranial neuralgias and central 13. Cranial neuralgias and central causes causes of facial pain of facial pain

14. Other headache, cranial neuralgia, 14. Other headache, cranial neuralgia, central or primary facial paincentral or primary facial pain

Tension-type headache (TTH) Tension-type headache (TTH) represents one of the Tension-type headache (TTH) represents one of the

most costly diseases because of its very most costly diseases because of its very high high prevalence.prevalence.

TTH is TTH is the most common type the most common type of headache, and it is of headache, and it is classified as classified as episodic (ETTH) or chronic (CTTH).episodic (ETTH) or chronic (CTTH).

It had various It had various ill-definedill-defined namesnames in the past in the past including tension headache, stress headache, muscle including tension headache, stress headache, muscle contraction headache, psychomyogenic headache, contraction headache, psychomyogenic headache, ordinary headache, and psychogenic headache. ordinary headache, and psychogenic headache.

Episodic tension-type headache

At least At least 10 previous headaches 10 previous headaches fulfilling fulfilling the following criteria; number of days the following criteria; number of days with such headache with such headache fewer than 15 per fewer than 15 per monthmonth

Headaches lasting from Headaches lasting from 30 minutes to 7 30 minutes to 7 daysdays

Characteristics of tension type headache

At least 2 of the following pain characteristics: At least 2 of the following pain characteristics:

Pressing/tightening (nonpulsating) qualityPressing/tightening (nonpulsating) quality

Mild or moderate intensity (may inhibit but does not prohibit activities)Mild or moderate intensity (may inhibit but does not prohibit activities)

Bilateral locationBilateral location

No aggravation from climbing stairs or similar routine physical activityNo aggravation from climbing stairs or similar routine physical activity

Both of the following: No nausea or vomitingBoth of the following: No nausea or vomiting

Photophobia and phonophobia absent or only one presentPhotophobia and phonophobia absent or only one present

Secondary headache types not suggested or confirmedSecondary headache types not suggested or confirmed

Chronic tension-type headacheAverage headache frequency of Average headache frequency of more than 15 days per month more than 15 days per month

for for more than 6 months more than 6 months fulfilling the following criteriafulfilling the following criteriaAt least 2 of the following pain characteristics: At least 2 of the following pain characteristics: Pressing/tightening (nonpulsating) qualityPressing/tightening (nonpulsating) quality Mild or moderate intensity (may inhibit but does not prohibit Mild or moderate intensity (may inhibit but does not prohibit

activities)activities) Bilateral locationBilateral location No aggravation from climbing stairs or similar routine No aggravation from climbing stairs or similar routine

physical activityphysical activity Both of the following: No vomitingBoth of the following: No vomiting No more than one of the following: nausea, photophobia, or No more than one of the following: nausea, photophobia, or

phonophobiaphonophobia Secondary headache types not suggested or confirmedSecondary headache types not suggested or confirmed

Pathophysiology of TTH Pathogenesis of TTH is Pathogenesis of TTH is complex and complex and

multifactorialmultifactorial, with contributions from both , with contributions from both central and peripheral factors. central and peripheral factors.

In the In the past,past, various mechanisms including various mechanisms including vascular, muscular (ie, constant overcontraction vascular, muscular (ie, constant overcontraction of scalp muscles), and psychogenic factors were of scalp muscles), and psychogenic factors were suggested.suggested.

The more likely cause of these headaches is The more likely cause of these headaches is believed believed nownow to be to be abnormal neuronal abnormal neuronal sensitivity and pain facilitation,sensitivity and pain facilitation, not abnormal not abnormal muscle contraction. muscle contraction.

Various evidence suggests that, like Various evidence suggests that, like migraine,migraine, TTH is associated with TTH is associated with exteroceptive suppression exteroceptive suppression (ES2), (ES2), abnormal abnormal platelet serotoninplatelet serotonin, and , and decreaseddecreased cerebrospinal fluid beta- cerebrospinal fluid beta-endorphin. endorphin.

EpidemiologyFrequency

Rasmussen et al reported a lifetime Rasmussen et al reported a lifetime prevalence of prevalence of TTH of 69% in men and TTH of 69% in men and 88% in women88% in women in the Danish population. in the Danish population.[2] [2] The patient may experience more than The patient may experience more than one primary headache syndrome. one primary headache syndrome.

Tension headache

SexSexWomen are slightly more likely to be affected than Women are slightly more likely to be affected than

men.men.The female-to-male ratio for TTH is approximately The female-to-male ratio for TTH is approximately

1.4:1.1.4:1.In CTTH, female preponderance is 1.9:1.In CTTH, female preponderance is 1.9:1.AgeAgeTTH can occur at TTH can occur at any ageany age, but onset during , but onset during

adolescence or young adulthood adolescence or young adulthood is common. It is common. It can begin in childhood.can begin in childhood.

History

Tension-type headaches (TTHs) are Tension-type headaches (TTHs) are characterized by pain that is characterized by pain that is usually mild or usually mild or moderatemoderate in severity and bilateral in in severity and bilateral in distribution. distribution.

Unilateral pain Unilateral pain may be experienced by 10-20% may be experienced by 10-20% of patients. Headache is a constant, tight, of patients. Headache is a constant, tight, pressing, or bandlike sensation in the frontal, pressing, or bandlike sensation in the frontal, temporal, occipital, or parietal area (with temporal, occipital, or parietal area (with frontal and temporal regions most common).frontal and temporal regions most common).

Physical

Patients with TTH have Patients with TTH have normal findings normal findings on on general and neurologic examinations.general and neurologic examinations.

Some patients may have tender spots or Some patients may have tender spots or taut bands in the pericranial or cervical taut bands in the pericranial or cervical muscles (muscles (trigger pointstrigger points).).

CausesVarious Various precipitating factors precipitating factors may cause TTH in may cause TTH in

susceptible individuals. susceptible individuals. One half of patients with TTH One half of patients with TTH identify stress or hunger identify stress or hunger as a precipitating factor. as a precipitating factor.

Stress - Usually occurs in the afternoon after long Stress - Usually occurs in the afternoon after long stressful work hoursstressful work hours

Sleep deprivationSleep deprivation Uncomfortable stressful position and/or bad postureUncomfortable stressful position and/or bad posture Irregular meal time (hunger)Irregular meal time (hunger) EyestrainEyestrain

Differential Diagnoses

Aseptic MeningitisAseptic Meningitis

Lyme DiseaseLyme Disease

Migraine HeadacheMigraine Headache

Migraine VariantsMigraine Variants

Pseudotumor CerebriPseudotumor Cerebri

Laboratory Studies

The diagnosis of tension-type headache The diagnosis of tension-type headache (TTH) is (TTH) is clinical.clinical.

As with the other primary headaches, As with the other primary headaches, no no specific diagnostic test is available for specific diagnostic test is available for TTH. TTH.

Occasionally, studies may be required to Occasionally, studies may be required to exclude secondary headache exclude secondary headache disorders.disorders.

Imaging StudiesNeuroimaging studies are important to rule out Neuroimaging studies are important to rule out

secondary causes of headache, including neoplasms secondary causes of headache, including neoplasms and cerebral hemorrhage.and cerebral hemorrhage.

MRIMRI imaging shows the greatest detail of cerebral imaging shows the greatest detail of cerebral structures and is especially useful in evaluating the structures and is especially useful in evaluating the posterior fossaposterior fossa..

CT CT scan with contrast is a viable alternative but is scan with contrast is a viable alternative but is inferior to MRI for viewing structures in the inferior to MRI for viewing structures in the posterior fossa.posterior fossa.

NeuroimagingNeuroimaging is indicated if the headaches are is indicated if the headaches are atypical in any way or if they are associated with atypical in any way or if they are associated with abnormalities in the neurologic examination. abnormalities in the neurologic examination.

Migraine Headache Practice Essentials

Migraine is a complex disorder Migraine is a complex disorder characterized by characterized by recurrentrecurrent episodes of episodes of headache, most often headache, most often unilateralunilateral and in and in some cases associated with visual or some cases associated with visual or sensory symptoms—collectively known sensory symptoms—collectively known as an as an auraaura—that arise most often before —that arise most often before the head pain but that may occur during the head pain but that may occur during or afterward. or afterward.

Migraine is most common in Migraine is most common in womenwomen and and has a strong genetic component.has a strong genetic component.

Signs and symptomsTypical symptoms of migraine include the following:Typical symptoms of migraine include the following: Throbbing or pulsatile headache, with moderate to severe Throbbing or pulsatile headache, with moderate to severe

pain that intensifies with movement or physical activitypain that intensifies with movement or physical activity Unilateral and localized pain in the frontotemporal and Unilateral and localized pain in the frontotemporal and

ocular area, but the pain may be felt anywhere around the ocular area, but the pain may be felt anywhere around the head or neck head or neck

Pain builds up over a period of 1-2 hours, progressing Pain builds up over a period of 1-2 hours, progressing posteriorly and becoming diffuseposteriorly and becoming diffuse

Headache lasts 4-72 hoursHeadache lasts 4-72 hours Nausea (80%) and vomiting (50%), including anorexia and Nausea (80%) and vomiting (50%), including anorexia and

food intolerance, and light-headednessfood intolerance, and light-headedness Sensitivity to light and soundSensitivity to light and sound

Features of migraine aura are as follows:May May precede or accompany precede or accompany the headache phase or the headache phase or

may occur in isolationmay occur in isolationUsually develops Usually develops over 5-20 minutes over 5-20 minutes and lasts less and lasts less

than 60 minutesthan 60 minutesMost commonly Most commonly visualvisual but can be sensory, motor, but can be sensory, motor,

or any combination of theseor any combination of theseVisual symptoms may be Visual symptoms may be positive or negativepositive or negativeThe The most common positive visual phenomenon most common positive visual phenomenon is is

the scintillating scotoma, an arc or band of the scintillating scotoma, an arc or band of absent vision with a shimmering or glittering absent vision with a shimmering or glittering zigzag border zigzag border

Physical findings during a migraine headache may include the following:Cranial/cervical Cranial/cervical muscle tendernessmuscle tendernessHorner syndrome Horner syndrome (ie, relative miosis with 1-2 mm (ie, relative miosis with 1-2 mm

of ptosis on the same side as the headache)of ptosis on the same side as the headache)Conjunctival injectionConjunctival injectionTachycardia or bradycardiaTachycardia or bradycardiaHypertension or hypotensionHypertension or hypotensionHemisensory or hemiparetic neurologic deficits Hemisensory or hemiparetic neurologic deficits

(ie, complicated migraine)(ie, complicated migraine)Adie-type pupil Adie-type pupil (ie, poor light reactivity, with near (ie, poor light reactivity, with near

dissociation from light)dissociation from light)

Diagnosis

The diagnosis of migraine is based on The diagnosis of migraine is based on patient historypatient history . . IHS diagnostic IHS diagnostic criteriacriteria are that patients must have are that patients must have

had had at least 5 headache at least 5 headache attacks that lasted 4-72 hours attacks that lasted 4-72 hours (untreated or unsuccessfully treated) and that the (untreated or unsuccessfully treated) and that the headache must have had at least 2 of the following headache must have had at least 2 of the following characteristicscharacteristics : :

Unilateral locationUnilateral locationPulsating qualityPulsating qualityModerate or severe pain intensityModerate or severe pain intensityAggravationAggravation by or causing avoidance of routine by or causing avoidance of routine

physical activity (eg, walking or climbing stairs)physical activity (eg, walking or climbing stairs)

In addition, during the headache the In addition, during the headache the patient must have had at least 1 of the patient must have had at least 1 of the following:following:

Nausea and/or vomitingNausea and/or vomiting Photophobia and phonophobiaPhotophobia and phonophobia Finally, these features must not have Finally, these features must not have

been attributable to another disorder.been attributable to another disorder.

Classification of migraine Migraine Migraine without aura without aura (formerly, common migraine)(formerly, common migraine) Probable migraine without auraProbable migraine without aura Migraine Migraine with aura with aura (formerly, classic migraine)(formerly, classic migraine) Probable migraine with auraProbable migraine with aura Chronic migraineChronic migraine Chronic migraine associated with Chronic migraine associated with analgesic overuseanalgesic overuse Childhood periodic syndromes Childhood periodic syndromes that may not be that may not be

precursors to or associated with migraineprecursors to or associated with migraine Complications of migraineComplications of migraine Migrainous disorder not fulfilling above criteriaMigrainous disorder not fulfilling above criteria

Migraine variants include the following:Childhood periodic syndromesChildhood periodic syndromes

Late-life migrainous accompanimentsLate-life migrainous accompaniments

Basilar-type migraineBasilar-type migraine

Hemiplegic migraineHemiplegic migraine

Status migrainosusStatus migrainosus

Ophthalmoplegic migraineOphthalmoplegic migraine

Retinal migraineRetinal migraine

migraine variant

A migraine variant may be suggested by focal A migraine variant may be suggested by focal neurologic findings, such as the following, that neurologic findings, such as the following, that occur with the headache and persist temporarily occur with the headache and persist temporarily after the pain resolves: after the pain resolves:

Unilateral paralysis or weakness - Hemiplegic Unilateral paralysis or weakness - Hemiplegic migrainemigraine

Aphasia, syncope, and balance problems - Basilar-Aphasia, syncope, and balance problems - Basilar-type migrainetype migraine

Third nerve palsy with ocular muscle paralysis and Third nerve palsy with ocular muscle paralysis and ptosis, including or sparing the pupillary ptosis, including or sparing the pupillary response - Ophthalmoplegic migraineresponse - Ophthalmoplegic migraine

Testing and imaging studies Selection of laboratory and/or imaging studies to Selection of laboratory and/or imaging studies to

rule out conditions other than migraine headache rule out conditions other than migraine headache is determined by the individual presentation (eg, is determined by the individual presentation (eg, erythrocyte sedimentation rate and C-reactive erythrocyte sedimentation rate and C-reactive protein levels may be appropriate to exclude protein levels may be appropriate to exclude temporal/giant cell arteritis). temporal/giant cell arteritis).

Neuroimaging is not necessary in patients with a Neuroimaging is not necessary in patients with a history of recurrent migraine headaches and a history of recurrent migraine headaches and a normal neurologic examination.normal neurologic examination.

What is a Migraine Aura?

Migraine Triggers

FoodFood

Disturbed sleep patternDisturbed sleep pattern

Hormonal changesHormonal changes

DrugsDrugs

Physical exertionPhysical exertion

Visual stimuli Visual stimuli

Auditory stimuli Auditory stimuli

Olfactory stimuli Olfactory stimuli

Weather changes Weather changes

HungerHunger

Psychological factorsPsychological factors

Triggers: Changes in Daily Cycles

Triggers: Environment or Diet

Triggers: Mental

Migraine

Major Forms:Major Forms: Migraine without aura (common) 70%Migraine without aura (common) 70% Migraine with aura (classical) 25%Migraine with aura (classical) 25% Migraine variants and complicated Migraine variants and complicated

migraine 5%migraine 5%

Phases of Acute Migraine

ProdromeProdrome

AuraAura

HeadacheHeadache

PostdromePostdrome

The Stages of a Migraine Attack

PRODROME Vague premonitory symptoms that begin from Vague premonitory symptoms that begin from

12 to 36 hours before the aura and headache12 to 36 hours before the aura and headache Symptoms includeSymptoms include

YawningYawning ExcitationExcitation DepressionDepression LethargyLethargy Craving or distaste for various foods Craving or distaste for various foods

Duration – 15 to 20 minDuration – 15 to 20 min

AURAAura is a warning or signal beforeAura is a warning or signal before

onset of headacheonset of headache

SymptomsSymptoms

Flashing of lightsFlashing of lights

Zig-zag linesZig-zag lines

Difficulty in focussingDifficulty in focussing

Duration : 15-30 minDuration : 15-30 min

HEADACHE Headache is generally unilateral and is Headache is generally unilateral and is

associated with symptoms like: associated with symptoms like: Anorexia Anorexia NauseaNausea Vomiting Vomiting PhotophobiaPhotophobia PhonophobiaPhonophobia Tinnitus Tinnitus

Duration is 4-72 hrs Duration is 4-72 hrs

POSTDROME (RESOLUTION PHASE)

Following headache, patient complains ofFollowing headache, patient complains of

FatigueFatigue

DepressionDepression

Severe exhaustionSevere exhaustion

Some patients feel unusually freshSome patients feel unusually fresh

Duration: Few hours or up to 2 daysDuration: Few hours or up to 2 days

Migraine Without AuraMigraine Without Aura Migraine With AuraMigraine With Aura

No aura or ProdromeNo aura or Prodrome Aura or prodrome is presentAura or prodrome is present

Unilateral throbbing headache Unilateral throbbing headache may be accompanied by nausea may be accompanied by nausea and vomitingand vomiting

Unilateral throbbing headache Unilateral throbbing headache and later becomes generalisedand later becomes generalised

During headache, patient During headache, patient complains of phonophobia and complains of phonophobia and photophobiaphotophobia

Patient complains of visual Patient complains of visual disturbances and may have disturbances and may have mood variationsmood variations

MIGRAINE: CLINICAL FEATURES

MIGRAINE - PATHOPHYSIOLOGY

VASCULAR THEORY

Intracerebral blood vessel vasoconstriction – aura

Intracranial/Extracranial blood vessel vasodilation –

headache

SEROTONIN THEORY

Decreased serotonin levels linked to migraine

Specific serotonin receptors found in blood vessels of brain

PRESENT UNDERSTANDINGNeurovascular process, in which neural events result in activation of blood vessels, which in turn results in pain and further nerve activation

NEUROVASCULAR PROCESS

Arterial Activation

Release of Neurotransmitter

Worsening of Pain

Triggers

Brain excitability

Cascade ofneurochemicalevents

NOglutamate5-HT

LumenLumen

Trigeminovascular activation

Afferent firing viatrigeminal nerve

Pain / headache

Cascade of events underlying migraine

1Migraine originates deep within the brain

2Electrical impulses spread to other regions of the brain.

3Changes in nerve cell activity and blood flow may result in visual disturbance, numbness or tingling, and dizziness.

4Chemicals in the brain cause blood vessel dilation and inflammation of the surrounding tissue

5The inflammation irritates the trigeminal nerve, resulting in severe or throbbing pain

How Migraine Works

Prognosis

Migraine is a chronic condition, but Migraine is a chronic condition, but prolonged remissions are common. One prolonged remissions are common. One study showed that among persons who study showed that among persons who had migraine during childhood, 62% had migraine during childhood, 62% were migraine free for more than 2 years were migraine free for more than 2 years during puberty and as young adults but during puberty and as young adults but that only 40% were still migraine free at that only 40% were still migraine free at age 30 years.age 30 years.

The severity and frequency of migraine The severity and frequency of migraine attacks tend to diminish with increasing attacks tend to diminish with increasing age. After 15 years of suffering migraines, age. After 15 years of suffering migraines, approximately 30% of men and 40% of approximately 30% of men and 40% of women no longer have migraine attacks.women no longer have migraine attacks.

Cluster Headache Cluster headache (CH), also known as histamine Cluster headache (CH), also known as histamine

headache, is headache, is a primary neurovascular primary a primary neurovascular primary headache disorder, headache disorder, the pathophysiology and the pathophysiology and etiology of which are not well understood.etiology of which are not well understood.[1] [1]

As the name suggests, CH involves As the name suggests, CH involves a grouping of a grouping of headaches, usually over a period of several headaches, usually over a period of several weeks. weeks.

According to the diagnostic criteria developed by According to the diagnostic criteria developed by the International Headache Society (IHS), CH has the International Headache Society (IHS), CH has the following characteristicsthe following characteristics

The patient experiences attacks of severe The patient experiences attacks of severe or very severe, strictly unilateral pain or very severe, strictly unilateral pain (orbital, supraorbital, or temporal pain) (orbital, supraorbital, or temporal pain) that last 15-180 minutes and occur from that last 15-180 minutes and occur from once every other day to 8 times a dayonce every other day to 8 times a day

The attacks are associated with 1 or more The attacks are associated with 1 or more of the following (all ipsilateral): of the following (all ipsilateral):

conjunctival injection, lacrimation, nasal conjunctival injection, lacrimation, nasal congestion, rhinorrhea, forehead and congestion, rhinorrhea, forehead and facial sweating, miosis, ptosis, or eyelid facial sweating, miosis, ptosis, or eyelid edemaedema

Cluster Headache ClassificationCH may be usefully classified into 2 main CH may be usefully classified into 2 main

forms as follows:forms as follows:

Episodic CHEpisodic CH, in which at least 2 cluster , in which at least 2 cluster phases lasting 7 days to 1 year are phases lasting 7 days to 1 year are separated by a cluster-free interval of 1 separated by a cluster-free interval of 1 month or longer month or longer

Chronic CHChronic CH, in which the clusters occur , in which the clusters occur more than once a year without remission more than once a year without remission or the cluster-free interval is shorter than or the cluster-free interval is shorter than 1 month 1 month

Medication overuse headaches

Affects 1 in 50 adultsAffects 1 in 50 adults Females:males 5:1Females:males 5:1 First noted with phenacetin/ergotamineFirst noted with phenacetin/ergotamine More common with aspirin/ More common with aspirin/

NSAIDs/paracetamol/codeine/DF118NSAIDs/paracetamol/codeine/DF118 Can take several weeks to resolve after Can take several weeks to resolve after

medication withdrawlmedication withdrawl Key feature-pre-emptive use of analgesiaKey feature-pre-emptive use of analgesia

Medication overuse headaches-cont. Low doses daily carry larger risk than Low doses daily carry larger risk than

higher doses weeklyhigher doses weekly Esp common if using simple analgesia Esp common if using simple analgesia

more days than not per monthmore days than not per month Using triptans, codeine >10days per monthUsing triptans, codeine >10days per month Worse on awakening in the morningWorse on awakening in the morning Worse after physical exertionWorse after physical exertion