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headache Headache is one of the commonest neurological complain reported at neurology clinic path physiology Intracranial pain sensitive structures include: the arteries of the circules of willis &the first few centimeters of their median sized branches Meningeal arteries Large veins &dural venous sinuses Extra cranial sensitive structures: external carotid arteires, scalp ,neck muscle ,skin & cutaneous nerves, cervical nerve &nerve roots, mucosa of the sinus &teeth .. Case history 25 y old f with h/o : ER h/o sever headache ,diffuse ,dull in nature ,not relived by analgesia,aggrevated by cough ,sneezing. Assosiated with vomiting No other neurological symptoms. She gave h/o of chronic infrequent headache ,which tension type and less sever, relieved by analgesia She is single Recently She was following with dermatology doctor and he gave her tablets for facial peeling O/E Neurological exam : HF:N Speech :normal Cranial nerves: fundoscopic exam:papilledema Motor, sensory, coordination :normal Is this headache serious? headache Primary (benign) secondary e.g(Migraine,tension,cluster) serious brain meninges parenchyma vacsular CSF systemic referred HPT ear,teeth anemia eye,sinus Secondary causes (serious) Structural causes Meninges: meningitis parenchyma : encephalitis ,abscess, tumor Vascular: hemorrhage, venous thrombosis, giant cell arterities Csf: increase CSF pressure (hydrocephalus ,pseudotumor cerebri) ,decrease CSF pressure…leak Careful history and examination should be done to differentiate between benign and serious headache Age Migraine headache: child hood or early adulthood Giant cell arteritis: >50 y New onset headache in elderly should be always a concern Onset Headache of many years duration &with little changes is almost always of benign origin New onset headache in old age or increasingly sever headache ….serious headache.. Hyperacute : SAH periodicity: episodic headache is benign Migraine ,Cluster headache a daily constant headache ..tension type duration Migraine: 4-72 h Cluster:1/2-2h Tension headache :build up over hours lasts days to years Location unilateral headache:migraine,cluster,temporal arterities . Tension headache : generalized ,frontal or posterior cervical region Carotid dissection commonly present with neck,face,and head pain usually ipsilateral to the dissection Local pain :superfacial structures Nature Nature: throbbing: vascular Tension :fullness, tightness, pressure like aura,& associated symptoms migraine: aura; focal cerebral symptoms associated with lasts from 20-30 min, precedes the headache Sensory, motor,autonomic,.. Cluster headache: ptosis,lacrimation, conjuctival , nasal congestion Headcahe +fever …..infection Transient visual obscuration, diplopia,tinnitus …increase intracranial pressure aura,& associated symptoms Jaw clawdication: temporal arteritis Headache: progressive+ central nervous symptoms is suggestive …structural brain lesion Aggravating & relieving Aggravating Cough, straining……intracranial pressure Activity., stress…..migraine, tension type Sitting: CSF hypotension Relieving: Rest…….migraine,tension Drug history Oral contraceptive… Cerebral vein thrombosis, migraine Steroid withdrawal Retin A tablets Warfarin : Hge pseudotumor cerebri Postpartum : cerebral venous thrombosis Recurrent abortion FH migraine exam v/s: fever ,BP General: sinus tenderness Eye ,throat ,ear exam exam Normal exam: benign headache Papilledema: increased intracranial pressure Focal neurological finding……serious Complicated migraine….neurological signs Horner syndrome: cluster headache Scalp tenderness, pulsless: temporal arteritis Is this headache serious? Characteristics of headache with serious underlying pathology History : Explosive onset and severe at onset No similar headaches in the past you have a constant headache, which is gradually getting worse; Altered mental status Age over 50 Immunosuppression Physical examination : Neurologic abnormalities Decreased level of consciousness Meningismus Papilledema Work up If history and exam is suggestive of serious headache Brain image: CT brain, mri brain If suspect cerebral vein throbosis..CT venogram ,MRV if fever or ? SAH …LP Go back to the case Case history 25 y old f with h/o : ER h/o sever headache ,diffuse ,dull in nature ,not relived by analgesia,aggrevated by cough ,sneezing. Assosiated with vomiting No other neurological symptoms. She gave h/o of chronic infrequent headache ,which tension type and less sever, relieved by analgesia She is single Recently She was following with dermatology doctor and he gave her tablets for facial peeling O/E Neurological exam : HF:N Speech :normal Cranial nerves: fundoscopic exam:papilledema Motor, sensory, coordination :normal Work up CT brain : normal MRI brain:N MRV: N LP: increased CSF pressure, protein, glu,cell count were normal Pseudo tumor cerebri ( Idiopathic Intracranial Hypertension ) Home message Careful history and exam including (opthalmoscopic) exam is the key to differentiate benign from serious headache.