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1、Headache,Dep. of Neurology,The First Affiliated Hospital of ZhengZhou University Haizhen Wang E-mail: Cell phone:13676970575,Instruction,Primary headache In most patients No physical signs Diagnosis is made entirely from the history Secondary headache The other disorders affecting the head and the n
2、eck Sometimes it is the predominantly symptom of serious intracranial disease, usually vascular , infective, or neoplastic,Instruction,Pain may be referred from the ears, eyes, nasal passage, teeth, sinuses, facial bones, and cervical spine. It is conveyed by the fifth, seventh, ninth, tenth cranial
3、 nerves, and the upper three cervical roots. Structure of the anterior and middle cranial fossa - anterior two-thirds of the head - the trigeminal nerve Structure of the posterior fossa - back of the head and neck - the upper cervical roots,Differential diagnosis,The approach to assessing a patient
4、with headache should be based on the temporal pattern of symptoms , especially the mode of onset and subsequent course , this may be: Recurrent and episodic Chronic and daily Subacute onset Acute onset,Recurrent and episodic,Recurrent and episodic headache is usually benign and is very rarely due to
5、 structure or progressive pathology Migraine Cluster headache Trigeminal neuralgia Benign exertional /cough headache Intermittent hydrocephalus Paroxysmal hypertension,Recurrent and episodic,Migraine Unilateral throbbing headache Exacebated by movement Accompanied by nausea, vomiting ,photo-,phona-a
6、nd osmophobia +/- aura symptoms,Recurrent and episodic,Cluster headache Severe unilateral retro-orbital +/- temporal pain Ipsilateral conjunctival injection , lacrimation Partial Horners syndrome Nasal blockage , rhinorrhoea Attacks last 15-180minutes and occur several times a day for about 2-3 mont
7、hs at a time,Recurrent and episodic,Trigeminal neuralgia Jabs of severe unilateral pain in the 2nd and 3rd distribution of the trigeminal nerve Triggered by actions such as chewing ,brushing teeth, talking ,cold wind Benign exertional /cough headache Headache induced by exertion, coughing, straining
8、 and sexual activity May be benign, but the diagnosis is one of exclusion,Recurrent and episodic,Intermittent hydrocephalus Intermittent severe headache accompany by drop attacks, weakness of the legs and unsteady gait, e.g. intermittent obstruction of the third ventricle by a colloid cyst Paroxysma
9、l hypertension This may occur in patients with a phaeochromocytoma,Chronic daily headache,Chronic daily headache is most offten diffuse tension-type headache and, again, is rarely due to serious intracranial disease Transformed migraine +/-analgesic oversue Tension-type headache +/-analgesic overuse
10、 Post-herpetic neuralgia Post-traumatic headache Atypical facial pain,Chronic daily headache,Transformed migraine +/-analgesic overuse Daily, mild, bilateral usually featureness Headache with superimposed episodes of Characteristic migraine headaches Tension-type headache+/-analgesic overuse Bilater
11、al featureless headache Usually episodic,Chronic daily headache,Postherpetic neuralgia After an attack of herpes zoster There may be continuous buring pain with superimposed occasional stabs in the distribution of the affected nerves Atypical facial pain Constant aching pain in the lower part of the
12、 face more commonly occurs in women It may follow a minor facial injury or dental procedure,Chronic daily headache,Post-traumatic headache Post-concussion headache Episodic headache which may be migrainous Generalized featureless daily headache Tenderness or pain located to the site of the injure Oc
13、cipital and/or neck pain from upper cervical spine injury,Subacute-onset headache,Includes most of the serious causes of headache. Subdural haematoma Intracranial tumor Intracranial abscess Chronic mengingitis Giant-cell arteritis Benign intracranial hypertension,Subacute-onset headache,Subdural hae
14、matoma History of head injury (elderly and alcoholics in particular), fluctuating level of consciousness, confusion, focal neurological signs (usually a hemiparesis) Intracranial tumour Headache exacerbated by coughing, sneezing, or straining May occur with obstruction of CSF pathways Focal neurolog
15、ical signs, seizure,Subacute-onset headache,Intracranial abscess Direct extension from local disease (e.g. frontal sinusitis) or metastatic spread (e.g. lung abscess) Fever, systemically unwell, focal neurological signs Can be diagnosed on CT or MRI,Subacute-onset headache,Chronic meningitis Tubercu
16、losis (note ethnic origin and HIV status), Cryptococcal (HIV), malignant, syphilitic Benign intracranial hypertension Young, overweight females Papilloedema, raised CSF pressure CT or MRI usually normal The lateral ventricles often appear small,Subacute-onset headache,Gaint-cell arteritis Patients u
17、sually over 50 years of age Female preponderance Associated polymyalgia rheumatica elevated ESR Tender thickened superficial temporal artery Giant-cell arteritis on biopsy Urgent steroid therapy often prior to biopsy,Acuteonset headache,Acute-onset headache including some causes: Subarachnoid haemor
18、rhage Cerebral haemorrhage Meningitis/encephalitis Acute hydrocephalus Hypertensive crisis Acute glaucoma First episode of migraine/cluster headache,Acuteonset headache,Subarachnoid haemorrhage Explosive-onset thunderclap headache Neck stiffness Photophobia +/-focal neurological signs if there has b
19、een intracerebral extension of blood CT head scan subarachnoid blood (within 48 hours) CSF-xanthochromia (12 hours to 1 week),Acuteonset headache,Cerebral haemorrage Note history of hypertension, anticoagulation Focal neurological signs depending on site of bleed CT head scan-intracerebral blood Men
20、ingitis/encephalitis +/-history of recent respiratory tract infection Fever, neck stiffness, +ve kernigs sign Inflammatory CSF,EEG,Acuteonset headache,Acute hydrocephalus Nausea,vomiting,diplopia(6th nerve palsy-false localizing sign) +/-papilloedema, ataxia of gait Diagnosis confirmed on CT head sc
21、an Hypertensive crisis Very high blood pressure There may be papilloedema There may be other features of phaeochromocytoma,Acuteonset headache,Acute glaucoma Pain typically frontal, orbital or ocular Accompanied by persisting visual impairment, fixed oval Pupil and conjunctival injection This is on
22、ophthalmological emergency First episode of migraine/cluster headache Migraine can present with an explosive thunderclap onset The diagnosis of a migraine aetiology is one of exclusion Unless recurrent episodes have occurred over several years,History,A good history ie essential to the diagnosis of
23、the type of headache. Determine: Mode of onset- acute, subacute, chronic, or recurrent and episodic Subsequent course-episodic, progressive, or chronic and persistent Site-unilateral or bilateral; frontal, temporal, or occipital; radiation to neck, arm, or shoulder,History,Character of pain-constant
24、, throbbing, stabbing, or dull/pressure-like Frequency and duration Accompanying feature-additional neurological symptoms, neck stiffness, autonomic symptoms Excerbating factors-movement, light, noise, smell (e.g. migraine); coughing, sneezing, bending (e.g. raised intracranial pressure),History,Ind
25、ucing factors-alcohol (cluster headache and migraine, menstruation (migraine) ,stress (most headaches are worse with stress), postural change (high or low intracranial pressure ),head injury (subdural haemorrhage or post traumatic headache) Particular time of onset-mornings (migraine, raised intracr
26、anial pressure), awoken at night (cluster headache),History,Past history of headache Family history-migraine, hypertension, intracranial haemorrhage General health-systemic ill-health, existing medical conditions Drug history-nalgesic abuse, recreational drugs.,Examination,When examination a patient
27、 with headache, look for : Focal neurological signs Signs of local disease of the ears, eyes,or sinuses; restriction of neck movements and pain; temporomandibular dysfunction; thickening of the superficial temporal arteries Signs of systemic disease Abnormal blood pressure Remember ,the clinical exa
28、mination is often entirely normal,Summary,Headache may be: Primary (e.g. migraine, tension-type headache, cluster headache) Secondary (e.g. subarachnoid haemorrhage meningitis, raised intracranial pressure),Summary,Firstly the temporal pattern of symptoms should be established A list of differential
29、 diagnosis of the possible causes should come to mind based on the established temporal pattern of symptoms The history and examination should further narrow the differential diagnosis and indicate which patients may have a secondary headache,Summary,Clinician should alert to the secondary headache
30、and prompt do further investigation Resent onset/short history (particlarly in middle age with no previous history of headache ) Recent change in established pattern or character of headache Increasing severity with resistance to appropriate and adequately tried treatment Associated features-neurological signs, seizures, personality change, fever, systemic ill-health,谢谢！,