This ppt consists of Evaluation of headache patients including neuroimaging and other investigations

1. Evaluation of
headache
Dr. Ravi Shankar Sharma
Moderator- Dr. Praveen Talawar

2. AIM:
• To have understanding of headache:-
Evaluation (History & examination).
Investigations related to Headache.
Imaging studies.
2

3. Contents:
• Introduction
• Causes & Red flags
• Evaluation (History & examination)
• Investigations in Headache
• Clinical Vignette
3

4. Introduction
• Most common medical symptoms and reasons for
neurologic consultation.
• Lifetime prevalence > 90% (United Kingdom).
• Primary and secondary headache disorders.
• History & examination (neurologic)Investigations
4

5. 5
Dowson A, Dahlof C, Tepper S, Newman L. Prevalence and diagnosis of
migraine in a primary care setting. Cephalalgia. 2002;22:590-591.

6. Steps of evaluation
• Causes and red flags
• History
• Examination
• Investigations
• Diagnostic blocks
6

7. Steps
7
Silberstein SD, Lipton RB, Goadsby PJ. Headache in Clinical
Practice. London, England: Martin Dunitz; 2002.

8. Pain generators
Extracranial structures
• Scalp
• Muscles
• Cervical
• TMJ joint
• Paranasal sinuses
• Teeth
Intracranial structures
• Blood vessels
• Meninges
• cranial nerves
8

9. Harrison’s neurology in clinical medicine-4th edition
9

10. Red flags
10

11. Classification (ICHD-3)
• The Primary Headaches
• The Secondary Headaches
• Painful Cranial Neuropathies,
• Other Facial Pain and Other Headaches
http://www.ihs-headache.org/ichd-
guidelines 11

12. 12

13. History
1. Age of onset:
 Migraine , TTH, Cluster headache-early (20-30yr.)
 Secondary headache- late onset
13

14. Location
14

15. Sec. Headaches locations
15
J. Headache Pain 17, 95 (2016).

16. Intensity
• Migraine – moderate /severe
• TTH- Mild to mod.
• Cluster – very severe
• Sudden & severe- SAH
16

17. Character of headache
17

18. Thunder Clap Headache
18

19. D/d of severe headache
19

20. Duration
• Migraine – 4 to 72hr.
• TTH- up to 7 days
• Cluster & other TACs- sec.
to min.
20

21. • Cluster -1 to 8/day at a particular time
• Migraine- 1-4attacks/month
• TTH- <1 day/month to >15 days/month
21

22. Aggravating/relieving factor
• Migraine – ↑menses, stress , empty stomach etc.
↓ sitting in dark room
• Cluster headache- ↑ Alcohol, vasodilators (NTG)
• TTH- ↓ Rest & meditation
• ↑ICT/Arnold chiari malformation- ↑ valsalva
22

23. Triggers
Visual stimuli
Flashing Lights
Anxiety, Stress and
Physical exertion
Lack of Sleep
Hormonal ChangesHeadache Foods Tyramine
Caffeine:
23
•Drugs
•Weather changes
•Psychological
factors
Disturbed
sleep
pattern
Auditory stimuli Olfactory stimuli
Hunger

24. Associated feature
• Nausea & vomiting- migraine, ↑ ICT, Infections
• Autonomic symptoms- cluster headache
• ↑ ICT, pituitary tumours - visual field defects
• Aura symptoms & premonitory symptoms-
Migraine
24

25. Prodromal
symptoms include
Lethargy
Craving for food
Distaste for foods
25

26. Visual Auras
26

27. 27
Bousser MG, et al. In: Wolff’s Headache And Other Head Pain. 2001

28. Impact on the daily activity
Migraine disability assessment(questionnaire)
how much migraines
disrupts normal activities
before treatment begins.
28

29. Family history
• Familial hemiplegic migraine – genetic influence
• Sec. headaches like cerebral aneurysm, brain
tumours.
29

30. Past history
• Change in character, pattern & severity of new
headache ( ? d/t sec. headache)
• Episodic to chronic type
30

31. Medicinal history
• OCP’s
• HRT
• Antihistaminics
• Nitrates
 Medication overuse
headache(Rebound
headache)
31

32. Co morbidities
• Dental , nose, sinus or ear abnormalities
Infection
• H/O head trauma
• Asthmatics – avoid Beta- blockers
• Depression & insomnia- Amitriptyline
32

33. • Physical examination-
If any abnormalities– Investigations & imaging
• General examinations-
Body habitus
Fever
Blood pressure
Skin changes
33

34. Systemic examination
Central nervous system:
1. Higher functions-
a) Memory
b) Concentration
c) Speech
d) Orientation
Higher function can be assessed by Mini Mental scale
34

35. 35

36. a) Neck – Local inflammation, R.O.M, Nucheal rigidity
(Meningitis, SAH, postr. fossa tumr).
b) Face – symmetry, ear, nose, eyes & teeth.
c) Scalp- swelling & redness
36

37. Palpation
37

38. • Percussion :- Tinel’s sign
• Auscultation :-Bruits over carotid/vertebral
arteries, orbits
38

39. Cranial nerve examination
39

40. 40
Olesen J, Tfelt-Hansen P, Welch KMA. The Headaches. 2nd
ed. Philadelphia, PA: Lippincott Williams & Wilkins;
2000:359-363.

41. 41
Wolff’s Headache And Other Head Pain. 7th ed. Oxford,
England: Oxford University Press; 2001:20.

42. DIAGNOSIS TESTING CT AND MRI
• Neuroimaging most sensitive diagnostic tool.
• Recurrent migraine CT & MRI is unnecessary except
Substantial change in headache pattern
H/o seizures
Focal neurologic symptoms or signs
• Consensus expert opinion MRI is more sensitive
42
Report of Quality Standards Subcommittee
of AAN. Neurology. 1994.

43. ACR- Recommendation
43

44. CT preferred
Fractures (calvarium)
Acute hemorrhage (subarachnoid,
intracerebral)
Paranasal sinus and mastoid air cell disease.
44
Practice Parameter: the utility of neuroimaging in the
evaluation of headache in patients with normal neurological
examinations . Neurology. 1994;44:1353-1354.

45. Sub-Arachnoid hemorrhage
45

46. Intracerebral Hemorrhage
46

47. Paranasal sinuses
47

48. MRI preferred
Vascular disease Cerebral infarction, Venous
infarction
Neoplastic disease brain tumors (Skull base),
Meningeal carcinomatosis and Pituitary tumors
InfectionsBrain abscess, Meningitis, Encephalitis
OthersChiari malformation, Foramen magnum
and upper cervical spine lesions, Pituitary apoplexy
48

49. Cerebral infarct
49

50. Venous infarcts
50

51. Brain tumors
51

52. Pituitary tumor
52

53. Infections
53

54. MR AND CONVENTIONAL
ANGIOGRAPHY
54
Leclerc X et al. Neuroradiology. 1999.

55. MR angiography
55

56. INDICATIONS FOR
GADOLINIUM-ENHANCED MRI
56
Bousser MG et al; Wall M et al; Mokri B et al In: Wolff’s Headache
And Other Head Pain. 2001. Tien RD et al. Am J Roentgenol. 1993.

57. LUMBAR PUNCTURE
57
Evans RE et al. In: Wolff’s Headache And Other Head
Pain. 2001.

58. CSF XANTHOCHROMIA AFTER SAH
SPECTROPHOTOMETRY
58
Vermulen M et al. J Neurol Neurosurg Psychiatry. 1989.

59. CSF constituents in meningitis and
encephalitis
59
Annals of Indian Academy of Neurology, August 2012, Vol
15, Supplement 1

60. ELECTROENCEPHALOGRAPHY
60
Report of Quality Standards Subcommittee of AAN.
Neurology. 1995.

61. General Medical Tests
• >50 years ,with headache Giant cell arteritis.
• ↓ pulsation and/or tenderness and/or thickening
of STA, jaw and/or claudication.
• ESR100 or higher, ↑CRP
• Thrombocytosis.
• Temporal artery biopsy vasculitic changes.
61

62. Special Lab tests
• Metabolic (pheochromocytoma)Urinary
catecholamines
• Laboratory assessment for Divalproex sodium
levels.
62

63. PLAIN X-RAYS
• Cervicogenic headache
C1–2 subluxation in R.A.
upper cervical spondylosis.
• Panoramic x-ray examination (TMJ) joints and
dental x -rays
63

64. Panoramic x-ray of TM joints
64

65. Special Examinations and Consultations
• Ophthalmology visual field testing, Tonometry,
slit-lamp exam.
• Dentist /oral surgeon dental or TMJ pathology
• ENT Tumors of the sinuses, nasopharynx &
neck, and inflammatory sinus disease.
65

66. Diagnostic blocks
66

67. USG- GON intervention
67
Hadzic's Peripheral Nerve Blocks and Anatomy for Ultrasound-Guided
Regional Anesthesia, 2nd Edition

68. Cases:
68

69. History
69
• 17 yrs female, A student
Chief complain:
• Headache- 3 years
• Location frontal & temporal
• frequency 5 to 7 attacks every month
• Character  Throbbing/ Pulsating type

70. H/o presenting illness
• Duration 4- 8 hours
• A/W photophobia and sometimes nausea.
• ↑ foul smell and excessive noise
• Preferred dark room during the attacks.
• No h/o fever, blurring of vision, trauma &
sympathetic symptoms.
70

71. Past history:- Non significant
 Family:
• Mother has similar type headache.
Personal history: Non significant
Medical history: + with PCM/ NSAIDS.
G.P.E , Systemic, Local Examination: NAD
71

72. Diagnosis
72

73. Thank
you
73

74. References :
1. Headache Classification Subcommittee of the International
Headache Society. The international classification of
headache disorders, 2nd edition. Cephalalgia 2004; 24(Suppl
1):1–160
2. Bartleson JD. When and how to investigate the patient with
headache. Semin Neurol 2006;26(2):163–170
3. Evans RW. Diagnostic testing for headache. Med Clin North
Am 2001;85(4):865–885
4. Frishberg BM. The utility of neuroimaging in the evaluation
of headache in patients with normal neurologic
examinations. Neurology 1994;44(7):1191–1197.
5. Smetana GW, Shmerling RH. Does this patient have temporal
arteritis? JAMA 2002;287(1):92–101.
74