Headache
It is pain in any part of the head. It may occur on one or both sides of the head. Headache can develop gradually and may last for less than an hour or several days depending on its severity.
There are various type pain sensitive areas in cranial structures such as scalp, dura, middle meningeal artery, falx cerebral , circle of wills and proximal segments of pial arteries.
Some insensitive pain structures are ependyma, choroid plexus, pial veins and brain parenchyma.
CLASSIFICATION OF HEADACHE
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PRIMARY · Benign · Recurrent · No organic disease -Primary consist of 3 types: Tension type Migraine Trigeminal autonomic cephalgias ; cluster headache - Secondary consist of 5 types: - Systemic inflation
- Head injury
- Vascular disorder
- Hemorrhage
- Brain tumor(<0.1%){due to increase in intracranial pressure}
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SECONDARY 1. Malignant 2. Organic disease
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Tension headache
-most common type of primary headache
· Middle aged females are more prominent of having this type of headache than males, around 20-45years of females experience this headache due to stress and poor diet intake.
· One third of cases associated with depression fullness or tightness or pressure band; doesn’t affect activities of daily living.
· Absence of vomiting, photophobia(sensitivity from light) and phonophobia (sensitivity from sound). Patient is never disturbed from sleep due to headache.
Fundus- no papilloedema(increase intracranial pressure)
Treatment
1.For acute attack some NSAID’s are recommended
2.Chronic tension type headache- prophylaxis with amitryptiline.
Migraine
- Episodic headache
- Started during school(10-15yrs); attacks increase in frequency and severity over time
Clinical features
-Aura – mainly visual aura is present, auditory is observed in 20% of people ; visual aura relies 20-30 minutes
-typical headache usually holocranial, throbbing pain in front temporal area, nausea present. After headache patient feel lethargic and depressed.
-Presence of zigzag lines
-Fortification spectra
-Scintillating scotoma (blind spot that obstruct part of vision), a days prior to attacks mood changes, irritability and depression can be noticed.
Presence of episodes in 4-72hrs photophobia/phonophobia/osmophobia (olfactophobia-hypersensitivity to odors).
Migraine theories
- Vascular theory
Blood vessel dilation
Vasoconstriction “aura”
Vasodilatation –“headache”
Triggers
- Glare
- Alcohol
- Stress
-Bright lights
- Sounds
- Lack of excess sleep
Pathology – CGRP (calcitonin gene related peptide)
Centre- trigemino vascular complex
Serotonin Theory
=Decrease serotonin
Rare types of migraine
1.Opthalmoplegic migraine- is a nervous system problem that affects eye and head; people with this rare condition get headache and pain around the eyeball, weakness of muscle. transient 3rd nerve palsy-completely reversible.
2.Basilar migraine- these headache starts in lower part of brain (brainstem). transient posterior circulation symptoms{ataxia,tinnitus,diplopia,vertigo}
3.Hemiplegic migraine- transient weakness on one side; changes like vision, speech and sensation may experience by the patient.
4.Retinal migraine- transient monoocular vision loss ; vision changes in one eye and may cause flickering lights or blurred vision.
5.Familial hemiplegic migraine - occurs generally due to change in a specific gene sequence { gene CACNA 1A, the ATPA1A2 gene and SCN1A gene}Calcium channelopathy
Acute migraine management
Mild migraine
Paracetamol or NSAID’s = naproxen 550mg twice a day,Ibuprofen 200-400 mg 3-4 times a day+ antiemetics
Moderate- severe migraine
Triptans, 5 HT beta agonist , oral – Rizatriptan 5-30 mg ,Sumatriptan (oral,nasal)
-other drugs such as ergot alkaloids used in classical migraine; contraindicated in coronary artery disease and cerebrovascular attack patients.
Prophylaxis of migraine
First line- propranolol
TCA {tricyclic antidepressants}- amitryptline
Second line- telmisartan(40mg twice a day)
Venlafaxine(37.5 mg per day)
Valproate
Third line –pizotifen
Flunarazine
Clonidine
Other modalities of treatment
1.Greater occipital nerve block
2.Onabotulinum toxin A
3.Suprorbital transcutaneous stimulation
4.CGRP antagonists
- by Dr. Ravi Ranjan
- by Dr. Tanya Sharma
