Headaches

Headache and
vertebrogenic syndromes
for students of Dentistry
Hana Kalistová
Department of Neurology of the
1st Faculty of Medicine and
General Teaching Hospital
Headaches - classification
• International Headache Classification
(IHS 1988):
- primary: manifestation of chronic
paroxysmal disease
- secondary: symptom of other disease
Primary headaches
• Migraine
• Tension headache
• Cluster headache and chronic
paroxysmal hemicrania
• Various headaches without structural
lesion
Secondary headaches
 Headache associated with traumatic injury (acute
and chronic)
 Headache associated with vascular disease (SAH,
stroke, intrakranial hematomas – subdural, epidural,
intracerebral, AV malformations, arteriitis,
dissection, phlebothrombosis)
 Headache associated with non-vascular intracranial
disease (intractranial infections, tumors, CSF
hypertension and hypotension)
 Headache caused by chemical substances or by
their discontinuation (acute or chronic abuse or
discontinuation of substances: alcohol, ergotamine,
analgesics, caffeine, narcotics, nitrates, steroids,…)
Secondary headache II
• Headache caused by infection outside the brain
• Headache associated with metabolic disturbances
(hypoxia, hypercapnia, hypoglycemia, dialysis)
• Headache or facial pain associated with diseases of skull,
neck, eyes, sinuses, teeth or some other facial or head
structures
• Neuralgia, pains of nerve trunks and deafferentation pains
(retrobulbar neuritis, diabetic neuritis, inflammation of
nerves – herpes zoster, thalamic headaches)
In differential diagnosis, the
most important is:
to soon detect severe, lifethreatening secondary
headache
Warning symptoms
• The first headache in patient older than 40 years
• Intensive headache with sudden onset
• Atypical headache unresponsive to common
treatment
• Headache in a patient with tumor or HIV infection
• Qualitative or quantitative disturbance of
consciousness
• Focal neurological finding (except from migraine
aura)
Life-threatening headaches
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Intracranial expansive process
Hydrocephalus
Bacterial or viral meningoencephalitis
Subarachnoid hemorrhage
Craniocerebral trauma
Examination methods
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Detailed medical history
Neurological examination
Brain CT
MRI
Lumbar puncture
Subarachnoid hemorrhage
(see lecture about stroke)
• Rupture of aneurysms in the Circle of Willis
• Elevation of BP (physical strain, anger,
coitus, defecation)
• Clinical picture:
- somnolence, sopor
- agitation, aggressivity, negativistic behavior
- meningeal syndrome (from min to hours)
Headache in SAH
• Developes during several seconds
• Bilateral localization, sometimes with
maximum in occipital region
• Accompanied by nausea, vomiting,
photo- and phono-phobia
• CAVE: may mimic CC syndrome
Tension headache
• the most common type of primary
headache /69% in men, 88% in women/
• Episodic tension headache /less than 15
days per month or 180 days/year/
• Chronic tension headache /more than 15
days per month or 180 days/year/
Character tof tension
headaches
• Duration: 30 min - 7 days
• pressure, non-pulsating character,
feeling of being constricted by tire
• mild to moderate intensity
• diffuse localization
• may be accompanied by mild photo- or
phono-phobia
Treament of tension
headaches
• Acute pain:
- common analgesics, muscle relaxants
• Chronic pain:
psychologist /autogenic training, biofeedback/
- physiotherapy /relaxation exercise/
- pharmacological /analgesic, anxiolytics,
muscle relaxants/
Migraine
• 2nd most frequent primary headache
• Prevalence is 6% men and 20%
women – 850 000 individuals in Czech
Republic
• Typical onset in childhood or
adolescence, earlier: migraine with aura
and migraine in boys
Incidence of migraine
Types of migraine
• Migraine without aura (80%)
(common migraine)
• Migraine with aura
(classic migraine)
Phases of migraine
Prodromal phase
Aura
Headache
Postdromal phase
Migraine – prodromal phase
• In 60% of pacients, several hours to
several days before headache
- physical (sensation of stiff neck)
- mental (irritability, fatigue)
- altered behavior (mood swings,
increased appetite)
Migraine – aura
- In 20% of pacients
- Duration to 60 min
- Begins before or during headache
Migraine - aura
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Visual (scintillation, scotomas)
Sensitive (hypesthesia, paresthesia)
Motor (mono-, hemipareses)
Speech disturbances (dysarthria,
aphasia)
Migraine – headache
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Duration: 4-72 hours
2-5x per month
Often pulsating
Moderate to severe intensity
Worsens with physical exertion
Unilateral (60%)
Migraine – accompanying
symptoms
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Nausea
Vomiting
Photophobia
Phonophobia
Odorophobia
Migraine – postdromal
symptoms
• Fatigue
• Relief
• Mood change
Treatment of migraine
• Acute
• Prophylactic
Pathogenesis of migraine
„Trigger“ faktory
Kortex
Thalamus
Hypothalamus
Nucleus raphe Locus
coeruleus
dorsalis
Dura mater
¨Ganglion nervi
trigemini
Triptany
AV anastomosa
Prodloužená
mícha
C1
C2
Goadsby & Olesen, 1996
Specific treatment of migraine
Agonists of 5HT1B/D receptors
triptans treat and terminate migraine attack
(??)
Specific treatment of migraine
Triptans:
 sumatriptan
 naratriptan
 zolmitriptan
 eletriptan
 frovatriptan
Nonspecific treatment of migraine
Analgesics – do not cure, only make pain
milder
Risks:
Ineffectiveness of analgesic (u 50%)
Excessive consumption of analgesics
Dependence
Development of severe chronic headaches
Higher incidence of side effects
• peptic ulcer
• damage to liver or kidneys
Chronic daily headache
• Complication of primary headaches
• Pain occurs more often, subsequently
presents with persistent milder intensity
and loses original paroxysmal character
and classic concomittant symptoms
Risk factors for transformation
• Excessive use of analgesic, especially
of those with central effect
• Neurotic personality (tendency to
anxiety and depression)
• Enviromental stress factors (work,
family)
• Menopause
Preventive therapy
• Severe course of migraine
• Inefficacy or contraindication of acute
therapy
• Side effects of acute therapy
• It is necessary to use it at least 3
months
• Reduces intensity and frequency of
attacks by 50%
Preventive treatment of
migraine
• Antiepileptic drugs (valproate,
gabapentin, topiramate)
• Antidepressants (amitriptyline, SSRI)
• Beta-blockers
• Antagonists of 5-HT2 receptors
• Antagonists of Ca - IV. type
Cluster headache
• Intensive, unilateral, periorbital or
temporal
• Duration: 15-180 min
• Frequency of attacks: 1-8x per day
• Especially men
Cluster headache –
accompanying symptoms
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Hyperemia of conjuctiva
Lacrimation (excessive tears)
Rhinorhoea
Sweating of face or forehead
Miosis
Ptosis
Oedema of eyelids
Congestion of nasal mucosa
Cluster headache
Cluster headache – acute
treatment
• Inhalation of oxygen
• Sumatriptan s. c. or nasal spray
• Methylprednisolone or dexamethasone
i. v.
• Lidocain nasal drops
Cluster headache - prophylaxis
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Prednisone or dexamethasone
Verapamil, nimodipine
Lithium
Antiepileptic drugs (valproate,
gabapentin, topiramate)
Chronic paroxysmal
hemicrania
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Occurs mostly in women
Frequency: more than 5 attacks per day
Duration: 2-45 min
Rensponsive to indomethacin
Neuralgia
• Headache, mostly paroxysmal, in
distribution territory of peripheral
nerve
Sensitive innervation of n. V
Neuralgia of trigeminal n.
• Primary (essencial, in 80-90% with
neurovascular problem – a. cerebelli
superior or PICA)
• Secondary: irritation of n. V by
pathological processes anywhere along
the nerve (tumors in posterior fossa,
multiple sclerosis, affected teeth,
paranasal sinuses or eyes, postherpetic,
damage to n. V in parasellar localization)
Primary neuralgia of trigeminal n.
• Unilateral, very intensive, whipping pain,
more often 2nd and 3rd branch of
trigeminal n.
• Duration: several seconds - minutes
• Accompanied by painful contraction of
mimic muscles (tic douloureux)
• Trigger point
• Normal neurological finding
Secondary neuralgia of
trigeminal nerve
• Localized also in the territory of the 1st
branch
• Dull pain, sometimes paresthesias,
fluctuating intensity
• Neurological examination: painful exit
sites of n. V, sensory disturbances, ev.
motor disturbances in innervation
territory of n. V + other symptoms
according to the character of lesion (PC
angle, MS,..)
Treatment of neuralgia
• Carbamazepine, phenytoin, gabapentin,
pregabalin, valproate, lamotrigine,
clonazepam, amitriptyline, baclofen
• Microvascular decompression of n. V
• Stereotactic neurosurgery – GAMA knife
(effect with latency of 1 month)
• Percutaneously through foramen ovale
(radiofrequency gangliolysis, retrogasserian glycerol
radiculolysis or retrogasserian thermolesion by
electrocoagulation)
Neuralgia of n. IX
• Paroxysmal pain in the location of the
tongue root, tonsils, ear or mandibular
angle
• Provoked by speech, swalllowing, cough
Neuralgia of genicular
ganglion
Neuralgia of genicular ganglion
• Often h. zoster etiology, eruption in
external auditory canal
• Pains are localized in ear (sensory
innervation of intermedial n.) and may
irradiate into maxilla and mandible
• Peripheral paresis of the facial n.,
sometimes vestibulocochlear n. is
affected as well (hypacusis, tinnitus,
vestibular symptoms)
Occipital neuralgia
• In the area of n. occipitalis major (root
C2)
• Diff. dg.- CC syndrome and processes
in posterior fossa
• Therapy: targeted injection of the nerve
N. occipitalis major
Neuralgia of superior
laryngeal nerve
• Localization: outer side of larynx,
submandibular area and under the ear
• Pain is triggered by: pressure to the
larynx, by swallowing, speech or
rotation of head
• Duration: minutes to hours
Vertebrogenic disease
Spine
Diagram of the vertebra
Longitudinal section of the
spine
Vertebrogenic disease
- Extraordinarily frequent, with marked socioeconomic impact
- 1% of population suffers from transient, 1%
from permanent vertebrogenic disease
- 1/3 of all sick leaves
- most often in the age of 45-60 years
- LS:C:Th
4:2:1
Muscle corset
- paravertebral muscles
- trunk muscles
- abdominal muscles
Posture disorders
Predisposing
conditions
• Injuries
• Exposure to cold
• Exertion during work, sports
- remaining in one position for
long time
- lifting heavy objects
- rotations
- vibrations
Sources of „vertebrogenic
pains“
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Paravertebral muscles
Ligaments and fasciae
Bone structures
Spinal nerve roots
Mechanisms of vertebrogenic
pains
• Muscle contractures
• Blocks and hypermobility of
intervertebral joints
• Compression of spinal nerve root by
prolapse of a disc, by a sequestrum,
osteophyts or in spondylolisthesis
• Destruction of bone - traumas, tumors,
rarely also inflammatory process
Severity grade of
vertebrogenic pains
• Simple back pine without radicular
symptoms
• Irritative radicular syndrome
• Destructive radikular syndrome
• Conus and cauda syndrome
• Oppression of spinal cord
Cervicocranial syndrome
• Medical history similar to expansive
process or SAH v posterior fossa
• Irradiation of pain with maximum into
occipital area
• Clinical examination
• CT, MRI
Dermatomes
on upper limbs
Cervicobrachial syndrome
• Pains from Cp to the shoulders and
upper limbs, with unclear borders,
without objective signs of radicular
lesion
• The most common cause: facet
syndrome – affliction of intervertebral
joints
Radicular syndrome C6
• Autodermography and hypesthesia in
C6 area
• Strength deficit and hypotrophy in
biceps brachii muscle
• Obj.: lower biceps reflex
• Diff. dg.: carpal tunnel syndrome
• EMG
Radicular syndrome C7
• Autodermography and hypesthesia in
C7
• Deficit of strength and hypotrophy in
triceps brachii muscle
• Lower triceps reflex
• EMG
Radicular syndrome C8
• Autodermography and hypesthesia in
C8
• Deficit of strength and hypotrophy of
interosseal muscles
• Lower reflex of flexors of digits
• Diff. dg.: syndrom kubitálního kanálu
• EMG
Algic syndrome of thoracic
spine
• Pseudoradicular: they mimic other
diseases (angina pectoris, myocardial
infarction) – provoked by physical
exertion, + reaction to nitroglycerin),
medical internal examination necessary
• Radicular: classic radicular syndromes
• RTG a MRI
Spondylogenic cervical
myelopathy I
• Disturbed function of C spine due
to compression by osteoproductive
or destructive alterations of spine
• Slowly progressing course
• Pain of C spine only in 70%
patients
Spondylogenic cervical
myelopathy II
• Clinically: affliction of upper motor
neuron for lower limb and of
lower/upper motor neuron for upper limb
• Spastic gait + disorder of fine motor
skills on upper limb (clumsy hand
syndrom)
Low back pain (lumbago)
• The most common disease of lumbar
spine
• Blockage of joints, affliction of soft
tissues (fasciae, ligaments,
paravertebral muscles)
Dermatomes on lower limbs
Motor innervation on lower
limbs
Radicular syndromes of
lumbar spine
• Pseudoradicular syndrome: mimic other
diseases. It is necessary to examine
hip, knee, SI joint and potential
urological or gynecological causes
• Radicular syndromes (compression of
the root, most often by the prolapse of
intervertebral disc)
Prolapse of intervertebral disc
Prolapse of intervertebral disc
Vertebrogenic diseases
Factors that accelerate degeneration:
- overloading the spine
- deficit of physical activity
For the function and morphology of the
spine, it is optimal:
- adequate physical load (various forms
of exercise)
Radicular syndromes on
lower limbs
• Clinically important: L5 and S1
• Medical history, clinical
examination
• CT (if examination of only 3
segments is sufficient)
• MRI
Radicular syndrome L5
• Frequent
• weakened extensor hallucis longus
muscle and tibialis anterior
• weakened patellar reflex, patient not
capable of standing on the heel
Radicular syndrome S1
• Frequent
• Weakness and atrophy of triceps surae
muscle (smaller circumference of the
shin)
• Objectively diminished pattelar reflex,
patient is not capable of standing on the
tip
Cauda syndrome
Cauda syndrome
• Compression of cauda by herniation or
sequestrum
• Pains irradiating to both lower limbs,
diminished reflexes in affected segments
• Perianogenital hypesthesia and lower anal
reflex
• Retention → urinary incontinence
• If suspected c.s., acute MRI must be done
• Cauda shall not remain without proper
care „overnight“!
Examination methods in
vertebrogenic diseases
• Medical history, clinical
examination
• Native RTG
• MRI, CT, ev. PMG
• Scintigraphy of bones
• EMG, SSEP, MEP
Treatment of vertebrogenic
diseases
• NSAID, analgesic drug of II.
type
• Relax in the bed
• Muscle relaxants
• Rehabilitation
• Surgery
Treatment
• Acute pains
• Chronic pains
- Total rest in the bed
- Adequate motor activity,
individual RHB
- Exposure to cold or
heat
- Test of the effect of heat
(less than 3 months)
- Analgesic drugs +
muscle relaxants
(more than 3 měsíce)
- Analgesic drugs + coanalgesics (muscle
relaxants only in acute
exacerbation)
Treatment II
• Analgesics and non-steroid
antiinflammatory drugs
- only short-term use
• Opiod analgesics
- in case of little effect or intolerance to
the I. type
• Muscle relaxants
- short-term use (max. 2 weeks)
Treatment III
• Root injections:
- Administration of local into anesthetics
to intervertebral foramen of
corresponding root (transient relief for
several hours)
- Epidural administration of steroids +
anesthetics (little effect in radiculopathy)
Surgery
• 1 – 3% of patients
• Most often because of prolapse of
intervertebral disc
• Probability of failure is 10-30% (failed
back surgery syndrome), in 5-18%: new
surgery is performed
Thanks for your attention.