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1. HEADACHE

2. PRIMARY HEADACHE SYNDROMES
• Tension type headache
• Migraine
• Trigeminal Neuralgia
• Atypical facial pain
• Cluster headache
• Benign paroxysmal
headaches

3. TENSION TYPE
• Most common-69%
• Episodic or chronic
• Gradual onset , radiate forward from occiput
• Bilateral, dull, tight, band like pain
• Less in morning, pain increase as day goes on
• No accompanying N,V, throbbing, sensitivity to
light, sound or movement

4. Pathophysiology
• Primary disorder of CNS pain modulation
• Precipitating factors
Stress: usually occurs in the afternoon after long
stressful work hours or after an exam
Sleep deprivation
Uncomfortable stressful position and/or bad
posture
Irregular meal time (hunger)
Eyestrain
Caffeine withdrawal
Dehydration

5. 2 Theories
Muscle tension around head and neck
Malfunctioning pain filter located in brain stem,
brain misinterprets information and interprets
this signal as pain. One of the main
neurotransmitters which is probably involved is
serotonin

6. Management
• Paracetamol,Aspirin,NSAIDs
• Behavioral approach-relaxation
• Chronic-amitriptyline

7. MIGRAINE
• 2nd most common-16%
• 15% women and 6% men
• Severe, episodic, unilateral,throbbing pain
• Nausea,Vomiting
• Sensitivity to light ,sound, movement
• Genetic predisposition

8. Classical Migraine or Migraine
with AURA
 Symptom Triad
Paroxysmal headache
nausea &/or vomiting
aura of focal neurological events(visual)
20-25%

9. AURA
• flashing lights, silvery zigzag lines moving across
visual field over a period of 20 minutes
sometimes leaving a trail of temporary visual
field loss
• Sometimes-Auditory ,Olfactory, gustatory
hallucinations
• Sensory aura-spreading front of tingling and
numbness, from one body part to another

11. Rare aura:
• Vertigo
• Aphasia
• Hemiparesis
• Delirium
Migraine with limb weakness-Hemiplegic
migraine
Symptoms of aura do not resolve leaving
permanent neurological damage-Complicated
migraine

12. Common Migraine or Migraine
without AURA
• Paroxysmal headache
• Vomiting +/-
• NO AURA

13. Simplified Diagnostic Criteria for
MIGRAINE
At least 2 of the + At least 1 of the
following: following:
• Unilateral pain
• Throbbing pain • Nausea/vomitting
• Aggravation by • Photophobia and
movement phonophobia
• Moderate or severe
intensity

14. Clinical phases of a migraine
attack
Vulnerability
Attack Initiation
Prodrome
Aura
Pain
Postdrome

15. Triggers
• Flashing lights • Menstruation
• Loud sounds • Pregnancy
• Strong odors • Menopause
• Stress • Oral Contraceptives
• Hunger • Sleep changes
• Fatigue • Caffeine
• Alcohol • Chocolate
• Smoking • Tyramine
• MSG

16. Pathophysiology of Migraine
• Cortical spreading
depression
• Vascular
• Low Serotonin
• Melanopsin receptor

17. Cortical spreading depression of
LEAO
• Dysfunction of ion channels-Quick
depolarization(activation) followed by long-
lasting depression over an area of cortex
• Release of inflammatory mediators
• Irritation of cranial nerve roots-trigeminal

18. Vascular
Vasoconstriction of blood vessels in brain-Aura
(begins in occipital lobe)
Vasodilatation of scalp blood vessels
Inflammation
Pain

19. Migraine Pain-Trigeminovascular
• Key pathway for pain is trigeminovascular input
from meningeal vessels
• Modulation of trigeminovascular input comes
from dorsal raphe nucleus, locus coeruleus and
nucleus raphe magnus

21. Management
• Acute attack-
aspirin/paracetamol+metoclopromide/
domperidone
• Severe attack-Sumatriptan
• Frequent attacks-
Propranolol,Amitriptyline,Sodium valproate or
Topiramate

22. Trigeminal Neuralgia
• Lancinating pain in 2nd
and 3rd divisions of
trigeminal nerve
• >50yrs
• Severe, brief ,repetitive
pain causing patient to
flinch
• Precipitated by touching
trigger zones—washing,
shaving, eating, cold wind

23. Pathophysiology
• Compression of trigeminal N by aberrant loop of
cerebellar arteries as nerve enters brainstem
• Other benign compressive lesions
• Multiple sclerosis- TN occurs due to plaque of
demyelination in trigeminal root entry zone

24. Management
• Carbamazepine-DOC
• Intolerant-Gabapentin/Pregabalin
• Injection of alcohol into peripheral branch of
nerve
• Posterior craniotomy to relieve vascular
compression of trigeminal nerve

25. Atypical facial pain
• Persistent idiopathic facial pain
• Continuous, burning/crushing,unremittent,
centred over maxilla usually left side
• Middle aged women
• Early form of trigeminal neuralgia
• Rx-Amitriptyline, Gabapentin

26. Other causes of facial pain
Sinusitis
• Frontal-pain more in morning, decreases as day
progresses, stooping and blowing nose increase
pain
• Ethmoid and Sphenoid-pain over vertex, less in
morning and increase gradually

28. Post herpetic
neuralgia-continuous,
burning pain
sensitive to light
touch, shingles

29. THANK YOU