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Scenario 1
25 y female was admitted to NFTH
with a severe headache as she got
up from the bed in the early hours of
the morning. The headache was
mainly occipital. On admission she
vomited twice and was in severe
pain.
Examination
normal
Scenario 2
25 year female was admitted with a
severe headache as she got up from
the bed in the early hours of the
morning. The headache was mainly
occipital and radiating down the
neck. On admission she vomited
twice and was in severe pain.
Past history - trauma to the neck last
year and was wearing collar.
EXAMINATION
Appeared drowsy
GCS 15/15
Neck stiffness ++
Causes
Primary
Secondary
Primary headache
migraine
Cluster
tension
Secondary headache
cranial
Extra-cranial
cranial
infection- meningitis, abscess
vascular- ICH,SAH
SOL- tumour, SDH
extracranial
toxic- viral, typhoid, leptospirosis
Hypertension
Referred from eye, ear, teeth,
sinuses, neck
Face-trigeminal neuralgia
Giant cell arteritis
Substance withdrawal
Psychiatric disorder
Types of Headache
Acute
Recurrent
Gradual
Chronic
Meningitis
Encephalitis
Sub Arachnoid haemorrhage
Head injury
Referred pain from sinuses ,ear,
teeth etc
Recurrent Headache
Migraine
Cluster Headache.
Gradual Headache
Space occupying lesion
Chronic Headache
Tension Headache
Hypertension
Increase Intracranial pressure.
(Benign/SOL)
Analgesic rebound headache.
Trigeminal neuralgia.
Migraine
very common.
3 phases
premonitory symptom- mood changes, anorexia
aura visual symptoms
Headache
Migraine
Unilateral, Pulsatile quality,
associated with Nausea, Vomiting.
Moderate to severe pain.
Photophobia
Phonophobia
Lasts for about 48 72hrs
Migraine
Ranked as the third most prevalent disorder and
seventh-highest specific cause of disability
worldwide.
Migraine has two major subtypes:
Migraine without aura- Recurrent headache
manifesting in attacks lasting 4-72 hours.
Typical characteristics of the headache are
unilateral
location,
pulsating
quality,
moderate or severe intensity,
aggravation by routine physical activity and
association with nausea and/or photophobia and
phonophobia.
aura
recurrent attacks,
lasting minutes, unilateral fully
reversible visual, sensory or other
central nervous system symptoms
that usually develop gradually
usually followed by headache and
associated migraine symptoms.
*
Pathophysiology
Not clearly identified.
Related to serotonin mechanism.
Decrease in serotonin results in
deficit in the pain inhibiting system.
Precipitating factors.
Emotions, Menstruation, Hypoglycemia,
Weather, Sleep, Alcohol,food
Treatment
Acute attack
Paracetamol
Ibuprofen
Diclofenac
Metocloprmide
Treatment
Ergot Alkaloids
Triptans - considered to be specific
treatment for migraine.
Serotonin (5-HT)agonists.
Inhibit the release of vasoactive peptides.
promotes vasoconstriction.
triptans
The serotonin 1b/1d agonists
effective for the acute treatment of
migraine
"specific" therapies for acute
migraine -in contrast to analgesics,
they act at the pathophysiologic
mechanism of the headache
mechanism
inhibit the release of vasoactive
peptides
promote vasoconstriction
block pain pathways in the brainstem
Preparations
sumatriptan, zolmitriptan,
naratriptan, rizatriptan, almotriptan,
eletriptan, and
Sumatriptan s.c injection
(autoinjector in the thigh), nasal
spray, oral
Zolmitriptan -both nasal and oral use
avoid
in patients with familial hemiplegic
migraine, basilar migraine
ischemic stroke
ischemic heart disease
uncontrolled hypertension
pregnancy
Prevention
Give prophylaxis if patient is having
more than 4attacks per month.
Propanolol.
Flunarazine.
Amytriptyline.
Use HCT during menstruation.
Tension Headache
Most frequent headache.
B/L Tightening pain.
No associated Nausea.
Treatment
NSAIDS
Prevention Tri Cyclic Antidepressants
Cluster headaches
Attacks of severe, strictly unilateral pain
which is orbital, supraorbital, temporal or in any
combination of these sites,
lasting 15180 minutes
occurring from once every other day to eight
times a day.
associated with ipsilateral conjunctival
injection, lacrimation, nasal congestion,
rhinorrhoea, forehead and facial sweating,
miosis, ptosis and/or eyelid oedema,
and/or with restlessness or agitation.
Cluster Headache
Unilateral
Severe pain
Usually Orbital or Supra orbital.
Lasts for 15mins 3hours.
Associated with lacrimation, Nasal
congestion.
Occurs in series of clusters weeks
to months.
Trigeminal neuralgia
Paroxysms of pain.
Pain is Stabbing or shocking in nature.
Lasts for seconds.
Common >50
triggering areas in the skin usually
ophthalmic or maxillary areas.
triggered by eating, talking, washing
face.
treatment: Carbamazapine
Intracranial Neoplasm
Intracranial Neoplasm.
Primary
Secondary
Clinical features
Headache feature of increased
Intracranial pressure.
Progressive neurological deficit.
Seizures.
Disturbance of the level of
consciousness.
Cognitive and behavioral
impairment.
Headache.
Vomiting.
Waking at night due to headache.
Headache worse on waking.
Papilloedema.
Progressive neurological
deficit
Hemisphere contra lateral
weakness, sensory disturbance,
vision loss, dysphasia.
Posterior fossa - Ataxia, Cranial
nerve palsy ( cranial nerve III & IV )
Cerebello pontine angle Deafness,
Ataxia, Facial sensory loss
Pituitary tumors Hyper or Hypo
secretion of hormones.
Malignant tumors
Type
Site
Age
Glioma
(Astrocytoma)
Cerebral
Hemisphere
Adult
Oligodendroglioma Cerebral
Hemisphere
Adult
Medulloblastoma
Childhood
Posterior fossa
Benign tumors
Type
Site
Age
Meningioma
Cortical dura
Parasaggital
Sphenoidal ridge
Adult
Neurofibroma
Acoustic Neuroma
Adult
Craniopharyngioma
Supra sella
Childhood
Pituitary adenoma
Pituitary
Adult
Colloid Cyst
3 rd Ventricle
Any age
Investigation
CT scan.
MRI scan.
MRI Particular value in Brain Stem
and posterior fossa tumors.
Management
Medical management Relieve
raised ICP by Dexamethasone.
Surgery is the mainstay of treatment.
Radiotherapy & Chemotherapy
Brain metastasis
Site
cerebellum,
cerebral
hemispheres.
Commonly from malignant tumors of
Bronchus, Breast, Colon and Renal
cell carcinoma.
Clinical features will depend on the
site of metastasis.
Management
Dexamethasone to reduce cerebral edema.
Surgical removal.
Paraneoplastic neurological
syndromes
Presents as a complication of cancer.
Symptoms may present before the
symptoms of malignancy.
Not due to direct or metastatic
invasion of the tumor.
Commonly associated cancers.
Small cell carcinoma of the lung, Breast
carcinoma, Gynocological cancers.
Presentation
Sensory neuropathy.
Lambert- Eaton Myasthenic
syndrome.
Polymyosities.
Dermatomyosities.
Cerebellar degeneration.
Subarachnoid hemorrhage
SAH
Blood in the subarachnoid space.
Can be due to
Traumatic
Spontaneous
Spontaneous SAH
Rupture of a berrys aneurysm of
circle of willis.
Commonly seen in the anterior
circulation of the circle of willis.
Commonly seen in anterior
communicating artery.
Others
AV malformations.
Ingestion of cocaine and Amphetamines.
Risk factors
Hypertension
Smoking
Alcohol
Clinical features
Sudden onset severe headache.
( Thunder clap headache ).
Lasts for hours or days.
Associated vomiting.
Loss of consciousness
Photophobia
Irritability
Physical exertion and sexual excitement
are preceding factors.
Signs
Neck stiffness
Kernigs sign + ve
III cranial nerve palsy due to
posterior communicating artery
aneurysm.
Subhyloid haemorrhages in fundus
examination
Management
Complications
Obstructive hydrocephalus.
Recurrent bleeding.
Cerebral ischemia due to vasospasm.
Treatment
Medical
Nimodipine
Surgical
Clipping of the aneurysm.
Inserting platinum coils to the aneurysm.