Dr Bhadresh B Mangukiya DMNeurology Clinic504Param doc ID: 785028
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Slide1
Differentiating Headaches ,testing and Management
Dr
Bhadresh
B
Mangukiya
D.M.Neurology
(Clinic-504,Param doc
House,Station
road ,
surat
)
Slide2Talk…………………..
Basic
stuctures
and pathophysiology
Primary or secondary headache?
Differ primary Headache?
What is natural History disease?
EEG ,MRI ,CT SCAN and OTHERS Role
When to start prophylaxis?
Drug of Choice?
Slide3Intracranial
Periosteum
Cranial nerves
Meninges
Meningeal arteries and dural sinusesProximal intracranial arteriesSphenoid sinusThalamic nucleiBrainstem pain-modulating centers
Extra-cranialScalpScalp musclesSkullCarotid and vertebral arteriesParanasal sinusesEyes and orbitsMouth, teeth, and pharynxEarsCervical spine and ligamentsCervical muscles
Pain-sensitive structures in the head and neck
Slide4What causes
Hedache
?
Slide5What are common causes?
Slide6Differential diagnosis of 906 patients who presented to a general neurology clinic with headache or facial pain as the major or only symptom
Diagnosis Number %
Tension headache 296 32
Migraine 241 27Headache ? Cause 139 15Post-traumatic 71 8Facial pain ?cause 38 4Depression 29 3Trigeminal neuralgia 29 3Cluster headache 19 2Malignant IC Tumour 14 1.5Benign IC Tumour 9Temporal arteritis 6Post-herpetic neuralgia 5Benign IC hypertension 4Cough headache 3Subdural haematoma 2
Sinus infection 1
Slide7Headache Diagnosis and Testing
Slide8Slide9Slide10Slide11Slide12SITUATION
DIFFERRENTIAL
WORK UP
Age > 50
Yrs Temporal Artritis, SOLESR, ImagingAge < 20 YrsSudden OnsetSAH, Pitutary Apoplexy, Mass Lesion, Hemorrhage into a mass lesion, Aneurysm Rupture.
Neuroimaging, L.P Increasing in Frequency & SeveritySubdural Hematoma, SOL, Med Over Use Neuroimaging, Med ScreeningNew Onset Headache in a Pt with Risk Factors ie HIV, Cancer Meningitis, Brain Abscess, Metastases“”Headache with Sign of Systemic Illness Fever, Neck Rigidity Meningitis, Encephalitis, Lyme Disease, Collagen Vascular Disease, Systemic Infection
Neuroimaging, L.P Serology Focal Neurological Signs
SOL, Stroke, Infarction, Collagen Vascular Disease
Neuroimaging,
Collagenvascular
evaluation
Incl
Antiphospholipid
antibodies.
Papilledema
SOL, BIH, Meningitis
Neuroimaging, L.P
Subsequent to Trauma
IC Hemorrhage, Sub/
Epi
dural
Hematoma,Post
Trauma Headache Neuroimaging of Skull, Brain & C Spine
RED FLAGS
Slide13Investigations
FBC & ESR.
X-Ray Skull,
Paranasal
Sinuses, Cervical Spine.CT Scan of the head.MRI of the Brain.Eye & ENT Evaluation.Cardiologic & Renal Evaluation.
Slide14Slide15Autonomi c Cephalgias
Slide16Migraine Terminology
m
igraineurs
: person who experiences migraines
aura: collection of symptoms that may precede or co-occur; typically visual, lasts less than 1 hourpositive featuresscintillations: a rapidly oscillating pattern of visual distortionsphotopsia: perception of flashes of lightteichopsia: spot of flickering lightnegative featuresscotoma: an area of diminished vision within the visual fieldhemianopsia: blindness in half of the visual field, may involve one or both eyeshemiplegic aura: occurring on one side of bodybasilar type aura: aura is localized to the brainstem
DiPiro et al. (2008). Pharmacotherapy: A Pathophysiologic Approach. p. 1008.
Slide17Presymptomatic hyperexcitabilty increases brain stem response to triggers
Release of Neurotransmitters
(5-HT, NE, DA, GABA, Glutamate, NO, CGRP, Substance P, Estrogen)
Neurotransmitters activate the Trigeminal Nucleus
Dilation of Meningeal blood vessels (Throbbing)Activation of Area Postrema (N/V)
Activation of Hypothalamus (Hypersensitivity)Activation of cervical trigeminal system (Muscle spasm)Activation of Cortex and Thalamus (Head pain)
Marcus, DA.
Headache Simplified
2008.
Slide18Neural Substrates of Migraine
Goadsby
et al. (2002).
New England Journal of Medicine, 346(4),
257-270.
Slide195-HT
1B
:
vasoconstriction
5-HT1D: peripheral neuronal inhibitionGoadsby et al. (2002). New England Journal of Medicine, 346(4), 257-270.
Slide20Hypothalamic & Insular Activation During Cluster Headache
9 patients with a history of cluster completed PET for regional cerebral blood flow at rest & following nitroglycerin
May et al. (1998).
Lancet, 352(9124),
275-278.
Slide21Slide22Slide23Slide24Slide25Slide26Slide27Slide28Migraine -visual aura
Bright shimmering 'stars' seen falling across the image (telischopsia).Bright-edged castellated line (fortification spectrum).
Scintilating
Scotoma
: A blind spot surrounded by a bright starburst. It is often mobile.
Loss, blanking or darkening of one half of the field of vision (
Hemianopia
)
Slide29Migraine -visual aura
Slide30Slide31Slide32Slide33Slide34Slide35Slide36Slide37Slide38Slide39Slide40Slide41Slide42Slide43Slide44Slide45Slide46Slide47Slide48Slide49Slide50Tnx…………