2. HEADACHES
‫د‬‫م‬‫حترم‬‫ف‬‫و‬‫پر‬‫ي‬‫سر‬‫وال‬‫ر‬‫نحو‬‫ر‬‫ح‬‫فيظ‬‫الدين‬‫صافي‬‫تر‬‫نظر‬‫الندي‬
‫هنما‬‫ر‬‫محترم‬‫استاد‬‫نجیب‬‫هللا‬‫توحیدوال‬
‫ترتيب‬‫كونكي‬‫داكتر‬‫عبدالحكيم‬‫صافي‬
2

3. Headaches

4. International headache society (IHS)
classification of headaches
Part I: The Primary Headaches
Part II: The Secondary Headaches
Part III: Cranial Neuralgias, Central and Primary Facial
Pain And Other Headaches

5. PRIMARY HEADACHE
A headache that is not caused by another
underlying disease, trauma or medical
condition.
1. Migraine, including:
 Migraine without aura
 Migraine with aura
 Childhood periodic syndromes that are commonly precursors
of migraine
 Cyclical vomiting
 Abdominal migraine
 Benign paroxysmal vertigo of childhood
2. Tension-type headache, including:
 Infrequent episodic tension-type headache
 Frequent episodic tension-type headache
 Chronic tension-type headache

6. 3. Cluster headache and other trigeminal autonomic
cephalalgias, including:
 Cluster headache
 Paroxysmal hemicrania
 Short-lasting unilateral neuralgiform headache attacks
with conjunctival injection and tearing
4. Other primary headaches, including:
 Primary cough headache
 Primary exertional headache
 Primary headache associated with sexual activity
 Primary thunderclap headache
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7. SECONDARY HEADACHECaused by exogenous disorders
1. Headache attributed to head and/or neck trauma, including:
 Chronic post-traumatic headache
2. Headache attributed to cranial or cervical vascular disorder,
including:
 Headache attributed to subarachnoid hemorrhage
 Headache attributed to giant cell arteritis
3. Headache attributed to non-vascular intracranial disorder,
including:
 Headache attributed to idiopathic intracranial hypertension
 Headache attributed to low cerebrospinal fluid pressure
 Headache attributed to non-infectious inflammatory disease
 Headache attributed to intracranial neoplasm

8. 4. Headache attributed to a substance or its withdrawal, including:
 Carbon monoxide-induced headache
 Alcohol-induced headache
 Medication-overuse headache
 Triptan-overuse headache
 Analgesic-overuse headache
5. Headache attributed to infection, including:
 Headache attributed to intracranial infection
6. Headache attributed to disorder of homoeostasis
7. Headache or facial pain attributed to disorder of cranium, neck,
eyes, ears, nose, sinuses, teeth, mouth or other
facial or cranial structures, including:
 Cervicogenic headache
 Headache attributed to acute glaucoma
8. Headache attributed to psychiatric disorder 8

9. Neuralgias and other headaches
1. Cranial neuralgias and central causes of facial pain
including:
• Trigeminal neuralgia
2. Other headache, cranial neuralgia, central or primary
facial pain
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10. 10
Causes of headaches
1. Traction or dilatation of intracranial or extra
cranial arteries.
2. Traction of large extra cranial veins
3. Compression, traction or inflammation of
cranial and spinal nerves
4. Spasm and trauma to cranial and cervical
muscles.
5. Meningeal irritation and raised intracranial
pressure
6. Disturbance of intracerebral serotonergic
projections

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12. PRIMARY HEADACHE
 MIGRAINE
1. Migraine without aura
2. Migraine with aura
3. Childhood periodic syndromes
4. Retinal migraine
5. Complications of migraine
6. Probable migraine

13. HISTOR and SYMPTOMS
 Periodic
 Headache types
 Time
 Character
 Causes
 State of health between attacks
 Visual disorders
 Nausea, Vomiting, Throbbing
 Photophobia phonophobia
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14. 14

15. 15

16. DIFFERENCIAL DIAGNOSIS
 Bacterial sinusitis
 Glaucoma
 Bacterial meningitis
 Sub arachnoid hemorrhage
 Pheochromocytoma
 AV- Malformation
 Hypertension
 Stress
 TIA, (TLE) Temporal lobe epilepsy
 Brain tumours
 Cluster headaches
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17. TREATMENT
 Reassurance
 Symptomatic
treatment
 Treatment of nausea
and vomiting
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Moderate Severe
Extremely
Severe
NSAIDs Naratriptan DHE (IV)
Isometheptene Rizatriptan Opioids
Ergotamine Sumatriptan
(SC,NS)
Dopamine
antagonists
Naratriptan Zolmitriptan
Rizatriptan Almotriptan
Sumatriptan Frovatriptan
Zolmitriptan Eletriptan
Almotriptan DHE (NS/IM)
Frovatriptan Ergotamine
Eletriptan Dopamine
antagonists
Dopamine
antagonists
DHE=Dihydroergotamine; NSAIDs=nonsteroidal anti-
inflammatory drugs

18.  Prophylactic Therapy
 5-HT2 antagonism - Methysergide
 Regulation of voltage-gated ion channels - Calcium
channel blockers
 Modulation of central neurotransmitters - Beta
blockers, tricyclic antidepressants
 Enhancing gamma-aminobutyric acid-ergic
(GABAergic) inhibition - Valproic acid, gabapentin
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20. TENSION HEADACHE
 HISTORY
 Headache type
 Time
 Character
 Cause
 Response to headache questions
 State of health between headache
attacks
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21. TYPES
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 Episodic TTH
 Chronic TTH
-.
nauseavomiting.
Bilateralandoccipitonuchalorbifrontalpain
Insomnia
.
occipitalfrontal.
Photophobiaand/orphonophobia
fullness,tightness/squeeze,pressure

22. Treatment
 Symptomatic treatment
 Prophylactic treatment
Non pharmacologic measures
Pharmacological measures
amitrytiline, mirtazipine, tizanidine
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24. CLUSTER HEADACHE
 Both male and female, very severe, strictly unilateral
 Last for an hour and may recure up to 8 times/day.
 Nocturnal attacks are common or may be in early
morning
 Secondary causes must be excluded and differentiation
between other trigeminal autonomic cephalalgias has
important treatment implications
 Oxygen, parenteral triptans and verapamil are the
treatments of choice

25. History
 Headache type
 Time
 Character
 Cause
 Response to headache
questions
 State of health between
headache attacks
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27. 27

28. Diagnostic criteria
 A. At least fi ve attacks fulfi lling criteria B–D
 B. Severe or very severe unilateral orbital, supraorbital and/or
temporal pain lasting 15–180 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 rhinorrhoea
3. ipsilateral eyelid oedema
4. ipsilateral forehead and facial sweating
5. ipsilateral miosis and/or ptosis
6. a sense of restlessness or agitation
 D. Attacks have a frequency from one every other day to eight
per day
 E. Not attributed to another disorder
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29. Differential diagnosis
 Anisocoria
 Basilar Artery Thrombosis
 Brainstem Gliomas
 Cavernous Sinus Syndromes
 Craniopharyngioma
 Headache: Pediatric Perspective
 Herpes Zoster
 Intracranial Hemorrhage
 Migraine Variants
 Persistent Idiopathic Facial Pain
 Pituitary Tumors
 Postherpetic Neuralgia
 Sinusitis Imaging
 Subarachnoid Hemorrhage
 Tolosa-Hunt Syndrome
 Trigeminal Neuralgia
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30. Treatment
 Abortive/symptomatic treatment
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a)Oxygen:8L/min for 10 min or 100% by mask
b)5-hydroxytryptamine-1 receptor agonist:triptans, ergot alkaloids,
metoclopramide
c)Opiates:
d)Intranasal civamide and capsaicin
e)Intranasal nasal administration of Lidocaine drops

31.  Preventive/prophylactic treatment
 Calcium channel blockers, verapamil, diltiazim can be combined with
ergotamin and lithium
Lithium
Corticosteroids high dose prednisolone that followed gradully
Methysergide
Tricyclic antidepressants
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32. HEADACHES AND SINUS DISEASE
 Introduction
 Sinusitis
 Headache
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33. HEADACHES RELATED TO SINUSITIS
 Sinusitis can be divided into many different categories,
but the simplest distinction is the difference
betweenAcute Sinusitis and Chronic Sinusitis
 Acute sinusitis
 Chronic sinusitis
 Acute exacerbation
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34. Diagnostic criteria by IHS
 Frontal headache
 Rhinosinusitis
 Remission after sinusitis treatment
 Drainage in the nasal cavity
 Nasal obstruction, decreased or absent sense of smell,
 Fever may or may not
 Chronic rhinosinusitis is not validated as a cause of
headache or facial pain except in cases of acute relapse.
 These headaches are caused by the pressure of mucus
against the lining of the sinus cavities when that mucus
becomes trapped and unable to drain into the nasal
cavity due to inflammation and swelling of the
openings 34

35. Tension Headache Cluster Headache Headache due to Rhinosinusitis
A. At least 10 episodes occurring
on <1 d/mo on average (<12d/y)
and fulfilling criteria B-D
B. Headache lasting 30min-7d
C. headache has at least 2 of the
following characteristics:
1. Bilateral location
2. Pressing/tightening
(nonpulsating) quality
3. Mild or moderate intensity of
pain
4. Not aggrevated by routine
physical activity (e.g., walking or
climbing stairs)
D. Both of the following:
1. No nausea or vomiting
(anorexia may occur)
2. No more than 1 of photophobia
or phonophobia
E. Not attributed to another
disorder
A. At least 5 attacks fulfilling
criteria B-D
B. Severe or very severe unilateral
orbital, supraorbital, and/or
temporal pain lasting 15-180 min if
untreated
C. Headache is accompanied by at
least 1 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. Sense of restlessness or agitation
D. Attacks have a frequency of 1 every
other day to 8/d
E. Not attributed to another disorder
A. Frontal headache accompanied
by pain in 1 or more regions of
the face, ears, or teeth and
fulfillingg criteria C and D
B. Clinical, nasal endoscopic, CT,
and/or MRI imaging and/or
laboratory evidence of acute or acute-
on-chronic rhinosinusitis
C. Headache and facial pain develop
simultaneously with onset or acute
exacerbation of rhinosinusitis
D. Headache and/or facial pain
resolve within 7d after remission or
successful treatment of acute or
acute-on-chronic rhinosinusitis
(Adapted from Headache Classification Subcommittee of the International Headache Society)
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36. HEADACHES RELATED TO OTHER
NASAL PROBLEMS
 Headache can also be caused decreased oxygen
saturation or nerve inflammation
 In certain cases these two causes may be found within
the nasal cavity itself
 Septal deviation and inferior turbinate hypertrophy
obstructive sleep apnea (OSA)
 The idea of a “contact point” headache
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37. Approach to Headaches
 Time questions
a) Why consulting now?
b) How recent in onset?
c) How frequent and what temporal pattern (especially distinguishing between episodic and daily or unremitting)?
d) How long lasting?
 Character questions
a) Intensity of pain?
b) Nature and quality of pain?
c) Site and spread of pain?
d) Associated symptoms?
 Cause questions
a) Predisposing and/or trigger factors?
b) Aggravating and/or relieving factors?
c) Family history of similar headache?
 Response to headache questions
a) What does the patient do during the headache?
b) How much is activity (function) limited or prevented?
c) What medication has been and is used, and in what manner?
 State of health between attacks
a) Completely well, or residual or persisting symptoms?
b) Concerns, anxieties, fears about recurrent attacks and/or their cause?
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39. Sinusitis :
 frontal and ethmoidal sinusitis,
 the pain tends to be worse on awakening
 gradually subsides when the patient is upright;
 Maxillary and sphenoidal sinusitis
 the opposite happens
 pain is ascribed to filling of the sinuses and its relief
to their emptying, induced by the dependent position of
the ostia.
 Bending over intensifies the pain by causing changes in
pressure, as does blowing the nose and air travel,
especially on descent,

40. Headache of ocular origin,
 Site :
 orbit, forehead, or temple, is of the steady,
 aching type
 follow prolonged use of the eyes in close work.
 Hypermetropia and astigmatism (rarely myopia),
 which result in sustained contraction of extra ocular as well as
frontal, temporal, and even occipital muscles.
 Correction of the refractive error abolishes the headache.
 Iridocyclitis and in acute angle closure glaucoma,
 in which raised intraocular pressure causes steady, aching
pain in the region of the eye, radiating to the forehead

41. Headache of upper cervical spine
 Headaches that accompany disease of ligaments,
muscles,and apophysial joints in the upper part of the
cervical spine
 are referred to the occiput and nape of the neck on the
same side and sometimes to the temple and forehead.
 Degenerative changes in the cervical spine
 Arthritic
 Pain on first movements after prolonged rest for some hours
are
stiff and painful.
 Pain of fibromyalgia:
 a controversial entity, is putatively characterized by tender
areas near the cranial insertion of cervical and other
muscles.

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