Power Point Presentation By Dr P L John

Power. Point Presentation By Dr. P. L. John Israel

$COMMON CAUSES • • Viral Rhinitis (Common Cold) Sinusitis Fevers Hypertension Refractive Error Tension$

COMMON CAUSES • • Viral Rhinitis (Common Cold) Sinusitis Fevers Hypertension Refractive Error Tension Headache Hypoglycemia Post ictal headache Power. Point Presentation By Dr. P. L. John Israel

SPECIFIC CAUSES • • • Migraine Headache Cluster Headache Temporal Arteritis Post traumatic Headache Thunderclap Headache (Subarachnoid Haemorrhage) Power. Point Presentation By Dr. P. L. John Israel

Specific Causes Contd. . • • Intracerebral Haemorrahage Subdural Haematoma Brain Abscess Primary Brain Tumor Metastatic Brain Tumor Meningitis Hydrocephalus Glaucoma Power. Point Presentation By Dr. P. L. John Israel

BRAIN • Seat of intelligence • By itself is not sensitive to pain but the adjacent structures protect the brain to make sure that the brain is safe. • Headache is like an alerting signal • Face and scalp are richly supplied by pain receptors than other parts of the body in order to protect the precious contents of the skull • Also the nasal, oral passages , eye and ear all are delicate and highly sensitive structures which reside here and must be protected Power. Point Presentation By Dr. P. L. John Israel

CRANIAL STRUCTURES SENSITIVE TO PAIN • • The scalp Scalp blood supply Head and neck muscles Great venous sinuses Arteries of the meninges Larger cerebral arteries Pain –sensitive fibers of the fifth, ninth and tenth cranial nerves • Parts of the dura mater at the base of the brain Power. Point Presentation By Dr. P. L. John Israel

• Migraine occurs commonly in – Females – 70% – Males – 30% • Cluster Headache occurs almost entirely in men – 90% • Tension Headache seen equally in both sexes Power. Point Presentation By Dr. P. L. John Israel

Location of Headache • • • Hemicranial Bi-Temporal Occipital Frontal Peri-Orbital Vertex Power. Point Presentation By Dr. P. L. John Israel

Nature of Headache • • Constant Paroxysmal Lancinating Throbbing Power. Point Presentation By Dr. P. L. John Israel

Power. Point Presentation By Dr. P. L. John Israel

MIGRAINE HEADACHE • Familial Disorder characterised by periodic, Commonly unilateral , often pulsa tile headache. • Age of onset – Begins in childhood , adolescents in early adult life and diminishes in frequency and severity during advancing years. (Typically begins in teenage years and seldom begins after 40 yeras of age) Power. Point Presentation By Dr. P. L. John Israel

TYPES • Classic Migraine or Neurologic Migraine – Is characterised by aura • Common Migraine – Migraine without aura • Ratio – Classic Migraine : Common Migraine 1 : 5 Power. Point Presentation By Dr. P. L. John Israel

CLASSIC MIGRAINE • Prodrome : – Occurs hours to days before headache and consists of change in mood, behavior, apetite and cognition. • Aura : – Occurs within 1 hour of headache, and is most commonly visual or sensory – Visual Aura • Most Common • Consist of photopsias, bright flashing lights, scintillating scotomas, field cuts and fortification spectra (zigzag lines / Teichopsia) Power. Point Presentation By Dr. P. L. John Israel

– Sensory Auras • Next most common feature • Characterized by numbness or paresthesiae in a limb – Motor Weakness and aphasia are less common • HEADACHE – Often unilateral (Hemicranial in 60% of ages) and throbbing in nature – Follows aura with in 60 minutes and lasts 4 – 72 hrs – Is associated with • • nausea, vomiting Photophobia (aversion to light) Phonophobia (aversion to sound) Power. Point Presentation By Dr. P. L. John Israel

– Headache may be relieved after vomiting – Is aggravated by strain, routine physical activity or rapid movement of the head – Some relief with pressure on temporal vessels – Strong Family History (80%) • Migraine attacks come once or twice per month, or three tp four times per year • There is a strong association with menstruation in females Power. Point Presentation By Dr. P. L. John Israel

• Common Migraine – Symptoms are similar to classic migraine but there are no aura • Precipitating factors – Foods rich in tyramine (Cheese, redwine) – Foods containing monosodium glutamine (Chinese and Mexican foods) – Foods containing Nitrates (Cold cuts – bologna, salami, smoked meats) – Pickled, fermented, marinated foods (pasta salads) – Alcoholic beverages (especially red wine) – Caffeinated beverages (soft drinks, tea and coffee) Power. Point Presentation By Dr. P. L. John Israel

ETIOPATHOGENESIS OF MIGRAINE • VASCULAR THEORY – Vascular Theory of Migraine states that the migraine aura is due to cerebral vaso constriction and that the migraine itself is caused by vasodilatation – Cerebral blood flow is decreased during migraine with aura but there is no changes in blood flow during migraine without aura – Controversial Power. Point Presentation By Dr. P. L. John Israel

• ROLE OF SEROTONIN – 90% in GI Tract – 10% distributed in the brain and platelets – During Migraine attack, serotonin levels in the blood may decrease where as urinary concentration may increase. – This shift in serotonin level may trigger changes in blood vessels and blood flow and also alter pain perception in the brain. Power. Point Presentation By Dr. P. L. John Israel

• ROLE OF SEROTONIN – Serotonin may thus play a role in the cause of migraine – Amtriptyline, nortryptyline & sumatriptan which have an effect on serotonin metabolism are therefore useful in migraine headache. Power. Point Presentation By Dr. P. L. John Israel

• SUBSTANCE - P – The intra and extra cranial vessels are innervated by small unmyelinated fibers derived from trigeminal nerve and subserve both pain and autonomic function. – Activation of these fibers releases substance P and other peptides into the vessel valve. – The peptides dilate the cerebral vessels and increase there permeability causing a throbbing headache. Power. Point Presentation By Dr. P. L. John Israel

Nitric Oxide generated by endothelial cells has been implicated as the cause of pain in migraine headache. Power. Point Presentation By Dr. P. L. John Israel

BASILAR MIGRAINE • Basilar artery or vertebra basilar migraine – Less common form – Prominent brain symptoms – Seen usually in young women with a family history of migraine – Have visual aura and may even develop temporary cortical blindness – There may be associated vertigo, staggering, incoordination of limbs, dysarthria and tingling both hands and feet and around the mouth Power. Point Presentation By Dr. P. L. John Israel

BASILAR MIGRAINE contd…. . – Exceptionally there can be period of coma or quadriplegia. – The symptoms lost 10 -30 minutes followed by headache which may be occipital – Some patients at the onset of headache may faint, or become confused or stuporous and this stage may persist for several hours or longer. Power. Point Presentation By Dr. P. L. John Israel

Ophthalmoplegic Migraine • Characterised by recurrent unilateral headaches associated with weakness of extra ocular muscles • Transient 3 rd nerve palsy with ptosis with or without involvement of the pupil is the usual picture. • 6 th nerve is early effected common in children • Paresis may persist even after headache for days to weeks. • Occasionally opthalmoparesis may remian permanent. Power. Point Presentation By Dr. P. L. John Israel

Retinal Migraine or Ocular Migraine • Characterised by retinal or optic nerve ischemia. • There may be retinal haemorrhages or narrowing of retinal venules during and attack. • Mono ocular blindness, disc edema may occur and vision recovers only partially after several months. • The retinal or ciliary circulation may be involved. Power. Point Presentation By Dr. P. L. John Israel

Post Traumatic Migraine • Occurs following trivial head injury there may be loss of sight, headache confusion for hours or days before recovering • In others there may be hemiparesis or aphasia Power. Point Presentation By Dr. P. L. John Israel

Abdominal Migraine • Seen in young children • Instead of complaining of headache the child appears limp and pale and complains of abdominal pain. • There may be vomiting and fever • There may also be disturbances in mood along with abdominal pain. Power. Point Presentation By Dr. P. L. John Israel

Hemiplegic Migraine • The infant, child or adult has episodes of hemiparesis that may outlast the headache. • Has autosomal dominant trait with a family history (familial hemiplegic migraine). Power. Point Presentation By Dr. P. L. John Israel

Complicated Migraine Or Migranous Infarction • Here the temporary nerologic symptom of migraine headache may remain permanent • Ex : A Homonymous visual field defect • Platelet aggregation, edema of the arterial wall increased coagulability of blood, intense prolonged spasm of vessels have all been implicated in the pathogenesis of arterial occlusion and strokes that complicate migraine Power. Point Presentation By Dr. P. L. John Israel

• In children with mitochondrial disease (MELASMitochondrial Myopathy- Encephalopathy Lactic Acidosis and Stroke like Episodes) • And in adults with rare vasculopathy (CADASIL – Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leuko Encephalopathy), Migraine is prominent feature Power. Point Presentation By Dr. P. L. John Israel

STATUS MIGRAINOSUS • Continuous migraine with unilateral throbbing and disabling headache. • May follow head injury or viral headache. Power. Point Presentation By Dr. P. L. John Israel

Premenstrual / Menstrual Migraine • Is thought to be due to withdrawal of estrogens. • Migraine attacks tend to cease during pregnancy in 75 -80% of patients • Oral contraceptive pills or associated with increased frequency and severity of migraine and may be even be associated with permanent neurologic deficit. Power. Point Presentation By Dr. P. L. John Israel

FOOTBALLERS MIGRAINE • Sudden jarring of the head may precipitate the migraine attack in susceptible footballers Power. Point Presentation By Dr. P. L. John Israel

TREATMENT OF MIGRAINE • Treatment of Acute Attack (Primary treatment) • Prophylactic treatment Power. Point Presentation By Dr. P. L. John Israel

Treatment of Acute attack (Primary Treatment) • Mild attack of migraine – Acetaminophen – NSAIDS • Severe attack – Ergot alkaloids: • Ergotamine /Dihydroergotamine (DHE) • Best given at the on set of attack – Is an α adrenergic agonist with a strong serotonin receptor affinity and has a vasoconstrictor action. Power. Point Presentation By Dr. P. L. John Israel

– Available as oral, sublingual, injectable and inhalation forms • 1 – 2 mg every half an hour (Dose ) Sublingual or to be swallowed • Maximum dose (8 mg) – A Single dose of promethazine (Phenergan) 50 mg or Metaclopramide (Reglan) 20 mg given along with ergotamine relaxes the patient and allays nausea and vomiting. – Caffeine 100 mg is thought on slim evidence to potentiate the effects of ergot and other medications for migraine – Reduces headache in 70 -75% of patients. Power. Point Presentation By Dr. P. L. John Israel

5 HT Receptor Agonists • Sumatriptan – Is effective at stopping acute attack of migraine headache – Can be given subcutaneously 6 mg – As intranasal spray 20 mg – Or orally 50 -100 mg – Provide relieve in 70% patients. • Side Effects – Chest tightness & flushing – Should not be used concomitantly with ergotamines or inpatients with heart disease Power. Point Presentation By Dr. P. L. John Israel

Other 5 HT Receptor Agonists • Zolmitriptan 2. 5 to 5 mg • Rizatriptan 10 mg – Doses can be repeated if needed in 2 hrs Power. Point Presentation By Dr. P. L. John Israel

MIDRIN • Is a combination medication that consists of dichloralphenazone (a muscle relaxant), isometheptene (a vasospasm agent) and acetaminophen. • May be used as abortive therapy (2 tabs with onset of headache) and one tab every hour after that, up to 5 tabs total. • As prophylaxis ( 1 tab 2 -3 times per day) Power. Point Presentation By Dr. P. L. John Israel

Prophylactic Treatment • When headache occur at frequency of 2 -3 per month the following drugs have been effective of prophylactic agents – Beta –Blockers • • Inderal – 20 mg TID can increase up to 240 mg /day Atenolol – 40 to 160 mg/day Timolol - 20 to 40 mg /day Metoprolol – 100 to 200 mg /day Power. Point Presentation By Dr. P. L. John Israel

• Sodium valproate - 500 mg/day (upto 1000 mg /day) • Calcium channel blockers – Verapamil - 180 to 240 mg /day – Nifedepine - 30 mg /day • Tricyclic Antidepressants (Amitriptyline, Imipramine) – Amitriptyline – 25 mg HS – OD increase upto 200 mg/day (increase 25 mg /week) – Side effects • • • Dry mouth Constipation Urinary hesitancy Sedation Weight gain, Power. Point Presentation By Dr. P. L. John Israel

• Methysergide – Serotonin agonist , vasoconstrictor. Highly effective for primary treatment but has side effects on prolonged use (Retroperitoneal fibrosis, Pulmonary fibrosis) – Dose : 2 to 6 mg/day • Other Drugs – – Clonidine – 0. 5 mg TID/day Cyproheptadine – 4 to 16 mg /day Flunarazine – 5 to 10 mg/day Indomethacin – 150 to 200 mg /day Power. Point Presentation By Dr. P. L. John Israel

CLUSTER HEADACHE • Also known has – Paroxysmal nocturnal cephalalgia – Migrainous neuralgia – Histamine cephalalgia – Red Migraine – Erythromelalgia of the Head Power. Point Presentation By Dr. P. L. John Israel

CLUSTER HEADACHE • So called because these headaches occur during a short time span. • The cluster then recurs periodically. • A typical cluster of headaches may last 4 -8 weeks with 12 headaches/day during the cluster. • Patient may be free 6 months to 1 year before another cluster of headache occurs. • They may be distinctly seasonal. • Young adult Men (20 -50 yrs age) are more affected then women • Male to Female ratio 5: 1 Power. Point Presentation By Dr. P. L. John Israel

SYMPTOMS • Abrupt onset of headache originating in the eye and spreading over the temporal area. • Pain extremely severe and last 2060 minutes • The headache associated with – Nasal stuffiness – Rhinorrhoea – Redness of the Eye – Flush and edema of the cheek Power. Point Presentation By Dr. P. L. John Israel

SYMPTOMS – There may also be partial Horner’s Syndrome with ptosis and miosis on the side of The Head pain. These autonomic phenomena are similar to those elicited by local action of histamine and was therefore previously called Horton’s Histamine Headaches – These headaches are usually nocturnal, between 12 hrs after the onset of sleep are several times during the night and day not associated with aura or vomiting. The headache recurs with remarkable regularity each day for periods that last over 6 -12 weeks Power. Point Presentation By Dr. P. L. John Israel

CAUSE AND MECHANISM OF CLUSTER HEADACHE • Not clear • Probably due to paroxysmal parasympathetic discharge mediated through the greater superficial petrosal nerve and sphenopalatine ganglion Power. Point Presentation By Dr. P. L. John Israel

CLUSTER MIGRAINE • These persons have characteristics of both migraine headache as well as cluster headache Power. Point Presentation By Dr. P. L. John Israel

TREATMENT • Ergotamine 2 mg at bedtime • Inhalation of 100% oxygen for 10 – 15 min at onset of the headache • Intranasal lidocaine or sumatriptan • Methysergide 2 -8 mg/day • Prednisolone - 75 mg / day for 3 days and then taper the dose • Verapamil – upto 480 mg /day • Lithium – 600 to 900 mg/day (blood level of lithium must be between 0. 7 to 1. 2 meq/Lt) • Indomethacin – 75 to 200 mg /day Power. Point Presentation By Dr. P. L. John Israel

Power. Point Lecture Presented by Dr. P. L. John Israel Prof & HOD , Department of Internal Medicine Power. Point Presentation By Dr. P. L. John Israel