Download “Management of Headaches”

“Management of Oculosystemic Headaches”
Carlo J. Pelino OD FAAO
Joseph J.Pizzimenti OD FAAO
Pennsylvania College of Optometry
Elkins Park, PA 19027
(215) 276 -6000
“Advanced” Level
Important Note:
A headache may be a symptom of a serious underlying condition.
It may call for an immediate diagnostic work-up and treatment plan.
•Most Headaches are fortunately benign, however some can herald potentially life
threatening disease
•The majority of Headaches ( > 90% ) are “primary headaches”
•Primary Headache = occur independent of an underlying pathology
•Secondary Headache = associated with some type of pathology
The optometrist’s challenge is to differentiate the primary headache syndrome from the
dangerous secondary headache syndromes
A secondary headache syndrome should always be kept in mind when a patient presents
with a history of headache !!!
The International Headache Society ( I H S ) has published a detailed classification of
headaches and their etiology
Anatomical Considerations:
•The brain parenchyma is insensitive to pain
•Pain-sensitive structures within the cranial cavity with the densest trigeminal
innervation comes from the following:
•Dural venous sinuses (nervi vasorum) and tributaries
•Parts of the “Dura” at the base of the skull
•Cerebral arteries at the base of the brain
•Cerebral veins
Some of the causes of intracranial headache in the “secondary headache”syndromes:
•Compression
•Inflammation
•Displacement
•Dilatation
•Traction
Some of the extracranial sources of head pain in the “secondary headache”:
•Muscles
•Extracranial arteries and veins of the head and neck
•Mucous membranes
Patient History:
The patient’s history is a very important tool in the evaluation of a complaint of
headache. History is the key to diagnosis. 95% of headache patients have a normal
examination
Ask Important Questions:
D = Duration
R = Relief
F = Frequency
L = Location
O = Onset
P = Pain
S = Severity
•Visual changes
•Neurological changes
•Eye changes
•Personal and Family history
Physical Examination:
Thorough Ophthalmologic and Neurologic examination
•Pupils (Horner’s Syndrome)
•Intraocular pressure (Acute Angle Closure Glaucoma)
•Dilated fundus exam (Disc Edema)
•Visual field (Space occupying lesion)
•Neurological testing (Test 12 cranial nerve function)
Urgent Headaches
•Giant Cell Arteritis
•Subarachnoid Hemorrhage
•Bacterial Meningitis
•Stroke Related Headache
•Malignant Hypertension
•Pituitary Apoplexy
Common Headaches
•Common Migraine
•Tension Headache
Special Headaches
•Brain Tumors
•Migraine with aura (Classic Migraine)
•Cluster Headache
•Idiopathic Intracranial Hypertension
•Ophthalmologic Headache
•Sinus Headache
Giant Cell Arteritis
Occlusive inflammatory process
Temporal or Occipital headache (80% of patients)
•The headache has no distincitive characteristics
•New headache in a patient > 60 years of age, consider GCA
Pain and tenderness of the scalp, face or oral mucosa, jaw claudication
Eye signs:
Pallid swollen disc ( Arteritic Anterior Ischemic Optic Neuropathy)
Central Retinal Artery Occlusion
Branch Retinal Artery Occlusion
Cranial 3,4,6 palsy
Treatment:
•Erythrocyte sedimentation rate
•C-Reactive Protein
•CBC (Thrombocytosis)
Subarachnoid Hemorrhage
Sudden onset of a severe headache… “The worst HA of my life”
Reaches maximum intensity in a few minutes and is then continual
•Phenomenon referred to as a “Thunder-Clap” Headache
•Also known as the “First and Worst” Headache
Causes:
•Ruptured Aneurysm (Posterior Communicating Artery)
•Arteriovenous vascular malformation
Important Note:
A sentinel headache can occur – bleeding may precede the acute headache by several
days or even weeks
Subarachnoid Hemorrhage
Eye Signs and Symptoms:
•Photophobia
•Disc swelling
•Pre-retinal hemorrhages (Terson’s Syndrome)
•Cranial Nerve Palsy (Diplopia)
•Visual field defects
•Visual field defects
Systemic Signs:
•Brief loss of consciousness at headache onset
•Nausea
•Vomiting
•Neurological deficits
•Stiff Neck
Subarachnoid Hemorrhage
“First and Worst” headache must have diagnostic procedures performed immediately
Work Up:
•CT without contrast is the test of choice for subarachnoid hemorrhage
•Lumbar puncture may also be necessary
•MRA (Magnetic Resonance Arteriography)
•Neurosurgery consultation
When the diagnosis is missed ~ 50% of patients bleed again within two weeks
Mortality obviously increases !!!
Stroke Related Headache
•Headache is about 3 times more common in cerebral hemorrhage than in Ischemic stroke
(abuts the meninges or blocks cerebrospinal fluid flow)
•Headache may vary widely depending on the size and location of the intraparenchymal
hemorrhage
•Carotid disease circulation can cause a frontal headache
Periorbital or Temporal on the ipsilateral side ~ 30% of the time
•Vertebrobasilar system disease has a posterior headache ~ 60% of the time
•CT scan in the emergency room can quickly rule out hemorrhage
A non-hemorrhagic infarct both CT and MRI may help
•MRA may also help in the diagnosis
Acute of Chronic Meningitis
•Intense headache is followed by a stiffness of the neck that prevents passive flexion of
the head on the chest
•The headache is slightly less acute than subarachnoid hemorrhage.
•The headache develops gradually over hours
•The headache at times is not the main feature. Look a the patients overall health
presentation. The patient may look ill, has a fever and nuchal rigidity
•The patient may also present with fever, loss of consciousness and neurological deficits
Acute or Chronic Meningitis
Eye Signs and Symptoms:
•Photophobia
•Disc Edema
Diagnosis and Treatment:
•MRI / CT followed by a lumbar puncture
•Lumbar Puncture = identify the infectious organism
•Treatment is with systemic antibiotics
Malignant Hypertension
Headache is “dull” or sometimes “pounding”
Headache is a cardinal feature of hypertensive encephalopathy
Eye Findings:
•Hypertensive retinopathy
•Hypertensive choroidopathy
•Disc edema
Systemic Findings:
•Extremely high blood pressure >200/120
•Possible change in mental status
•Seizures may occur
Treatment:
•Urgent admission to an ER / PCP for slow lowering of the BP
Pituitary Apoplexy
Patient experiences a “severe” headache
Visual loss may also occur (chiasm and or optic nerve involvement)
Ocular Findings:
•Bitemporal hemianopsia
•Ophthalmoplegia
•Pallor to the Optic Nerve
Systemic Findings:
•Blood in the subarchanoid space
•May have acute pituitary insufficiency (life threatening)
•Make sure the patient is not lethargic, hypotensive or hypoglycemic
Diagnosis and Treatment:
•MRI, Emergency Neurosurgery, hormonal replacement
Brain Tumor
•The greatest concern for most headache patients
•Patients with primary or metastatic brain tumors have a headache at the time
of diagnosis (~30%)
•Severe headache pain worse in the morning, nausea and vomiting = seen only in about
20% of patients
•Most often the headaches are intermittent, dull ache, unilateral and mild initially but
usually occur daily
•Headache usually occurs in 70% of brain tumor patients
Brain Tumor
A new or altered headache pattern may be grounds for brain imaging at any age
Most frequent initial symptom of a brain tumor is seizure or neurological dysfunction
The duration of survival in brain tumor patients depends on the cellular grade of the
tumor and not its size
The most common primary brain tumor is an astrocytoma
Brain tumor headaches usually do not disrupt sleep
The headache worsens with a change in body position, coughing, straining
Migraine
Classic Migraine Aura prior to a headache
Common Migraine No aura before the headache
Acephalic Migraine Aura appears without the
headache
Affects 25-30 million adults and children in the United States
Affects ~ 5% of men
Affects ~ 20% of women ( Estrogen and Progesterone play a significant role
Strong family history is common ~ (80%)
Typically last from 4 to 72 hours
Migraine is a diagnosis of exclusion in those cases that present with complicated visual
and neurological symptoms
Basilar Migraine
•Affect posterior cortex, cerebellum and brainstem
•Visual field defects, ataxia, vertigo
•May occur in childhood (episodic vertigo)
Hemiplegic Migraine
•Hemiparesis with a migraine headache
•Headache is contralateral to the hemiparesis
•Hemiparesis lasts longer than the headache
Ophthalmoplegic Migraine
•Rare and usually starts in childhood < 10 years old
•The third nerve is most commonly involved
Retinal Migraine
•Transient monocular loss of vision (black-out or gray-out of vision)
•Often described as “tunnel” vision loss