Headache王海珍

HeadacheDep.ofNeurology,TheFirstAffiliatedHospitalofZhengZhouUniversityHaizhenWangE-mail:[e-mail]:13676970575Instruction•PrimaryheadacheInmostpatientsNophysicalsignsDiagnosisismadeentirelyfromthehistory•SecondaryheadacheTheotherdisordersaffectingtheheadandtheneckSometimesitisthepredominantlysymptomofseriousintracranialdisease,usuallyvascular,infective,orneoplasticInstruction•Painmaybereferredfromtheears,eyes,nasalpassage,teeth,sinuses,facialbones,andcervicalspine.•Itisconveyedbythefifth,seventh,ninth,tenthcranialnerves,andtheupperthreecervicalroots.•Structureoftheanteriorandmiddlecranialfossa----anteriortwo-thirdsofthehead----thetrigeminalnerve•Structureoftheposteriorfossa---backoftheheadandneck----theuppercervicalrootsDifferentialdiagnosisTheapproachtoassessingapatientwithheadacheshouldbebasedonthetemporalpatternofsymptoms,especiallythemodeofonsetandsubsequentcourse,thismaybe:•Recurrentandepisodic•Chronicanddaily•Subacuteonset•AcuteonsetRecurrentandepisodicRecurrentandepisodicheadacheisusuallybenignandisveryrarelyduetostructureorprogressivepathology•Migraine•Clusterheadache•Trigeminalneuralgia•Benignexertional/coughheadache•Intermittenthydrocephalus•ParoxysmalhypertensionRecurrentandepisodic•MigraineUnilateralthrobbingheadacheExacebatedbymovementAccompaniedbynausea,vomiting,photo-,phona-andosmophobia+/-aurasymptomsRecurrentandepisodic•ClusterheadacheSevereunilateralretro-orbital+/-temporalpainIpsilateralconjunctivalinjection,lacrimationPartialHorner’ssyndromeNasalblockage,rhinorrhoeaAttackslast15-180minutesandoccurseveraltimesadayforabout2-3monthsatatimeRecurrentandepisodic•TrigeminalneuralgiaJabsofsevereunilateralpaininthe2ndand3rddistributionofthetrigeminalnerveTriggeredbyactionssuchaschewing,brushingteeth,talking,coldwind•Benignexertional/coughheadacheHeadacheinducedbyexertion,coughing,strainingandsexualactivityMaybebenign,butthediagnosisisoneofexclusionRecurrentandepisodic•IntermittenthydrocephalusIntermittentsevereheadacheaccompanybydropattacks,weaknessofthelegsandunsteadygait,e.g.intermittentobstructionofthethirdventriclebyacolloidcyst•ParoxysmalhypertensionThismayoccurinpatientswithaphaeochromocytomaChronicdailyheadacheChronicdailyheadacheismostofftendiffusetension-typeheadacheand,again,israrelyduetoseriousintracranialdisease•Transformedmigraine+/-analgesicoversue•Tension-typeheadache+/-analgesicoveruse•Post-herpeticneuralgia•Post-traumaticheadache•AtypicalfacialpainChronicdailyheadache•Transformedmigraine+/-analgesicoveruseDaily,mild,bilateralusuallyfeaturenessHeadachewithsuperimposedepisodesofCharacteristicmigraineheadaches•Tension-typeheadache+/-analgesicoveruseBilateralfeaturelessheadacheUsuallyepisodicChronicdailyheadache•PostherpeticneuralgiaAfteranattackofherpeszosterTheremaybecontinuousburingpainwithsuperimposedoccasionalstabsinthedistributionoftheaffectednerves•AtypicalfacialpainConstantachingpaininthelowerpartofthefacemorecommonlyoccursinwomenItmayfollowaminorfacialinjuryordentalprocedureChronicdailyheadachePost-traumaticheadache•Post-concussionheadache•Episodicheadachewhichmaybemigrainous•Generalizedfeaturelessdailyheadache•Tendernessorpainlocatedtothesiteoftheinjure•Occipitaland/orneckpainfromuppercervicalspineinjurySubacute-onsetheadacheIncludesmostoftheseriouscausesofheadache.•Subduralhaematoma•Intracranialtumor•Intracranialabscess•Chronicmengingitis•Giant-cellarteritis•BenignintracranialhypertensionSubacute-onsetheadache•SubduralhaematomaHistoryofheadinjury(elderlyandalcoholicsinparticular),fluctuatinglevelofconsciousness,confusion,focalneurologicalsigns(usuallyahemiparesis)•IntracranialtumourHeadacheexacerbatedbycoughing,sneezing,orstrainingMayoccurwithobstructionofCSFpathwaysFocalneurologicalsigns,seizureSubacute-onsetheadache•IntracranialabscessDirectextensionfromlocaldisease(e.g.frontalsinusitis)ormetastaticspread(e.g.lungabscess)Fever,systemicallyunwell,focalneurologicalsignsCanbediagnosedonCTorMRISubacute-onsetheadache•ChronicmeningitisTuberculosis(noteethnicoriginandHIVstatus),Cryptococcal(HIV),malignant,syphilitic•BenignintracranialhypertensionYoung,overweightfemalesPapilloedema,raisedCSFpressureCTorMRIusuallynormalThelateralventriclesoftenappearsmallSubacute-onsetheadache•Gaint-cellarteritisPatientsusuallyover50yearsofageFemalepreponderanceAssociatedpolymyalgiarheumaticaelevatedESRTenderthickenedsuperficialtemporalarteryGiant-cellarteritisonbiopsyUrgentsteroidtherapyoftenpriortobiopsyAcute–onsetheadacheAcute-onsetheadacheincludingsomecauses:•Subarachnoidhaemorrhage•Cerebralhaemorrhage•Meningitis/encephalitis•Acutehydrocephalus•Hypertensivecrisis•Acuteglaucoma•Firstepisodeofmigraine/clusterheadacheAcute–onsetheadache•SubarachnoidhaemorrhageExplosive-onsetthunderclapheadacheNeckstiffnessPhotophobia+/-focalneurologicalsignsiftherehasbeenintracerebralextensionofbloodCTheadscan–subarachnoidblood(within48hours)CSF-xanthochromia(12hoursto1week)Acute–onsetheadache•CerebralhaemorrageNotehistoryofhypertension,anticoagulationFocalneurologicalsignsdependingonsiteof