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UNDERSTANDINGHEADACHES

CharlesStockwell,O.D.TexasTechHealthSciencesCenterCharles.Stockwell@ttuhsc.edu

NoDisclosures

AHEADACHE/CEPHALAGIA• Painaroundforehead

• Mild,dullpressure

• Incidental,non‐recurring

• Typicallyshortlived

• Notusuallyaccompaniedbyothersymptoms

• Treatablewithmedicine,rest,andwater

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THEHEADACHE• PainindifferentlocationsoftheHead

• ExquisitePain

• ReoccurringPain

• Cangoonandonandon

• Otherassociatedsymptoms

• TreatablesometimesandsometimesNOT

UNDERSTANDINGHEADACHES• Howmanyofyouhaveheadaches?

• HowmanyofyouhavehadComplaintsfrompatientsaboutheadaches?– Prettycommoncomplaint.– WeareEyeDoctorsandtheyarecomplainingbecausetheythinktheireyesmaybecausingtheheadachesortheirDoctordoes.

• WhatCausesthem?

• Whataretheyfrom?

• WhataresomeQuestionstoAsk?

BECAUSEWEGETSOMANYCOMPLAINTS

•MOSTheadachesareNOTVisualBUT:–Wehavearesponsibilitytopatient–Weneedtor/osight/lifethreatingSx–Weneedtoreferappropriately

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HEADACHEEPIDEMIOLOGY• MostCommonComplaint– 70%areWomen.• 85%oftheUSpopulationhadsignificantheadaches• 1outof3peoplehavehadasevereheadache

• ManyheadachesarefeltaroundtheeyesbutUNCOMMONtobeofocularoriginandmajoritywithprimaryC/OdoNOThaveaseriousmedicalcausefortheproblem.

• MorecommoninFemalesthanMales(3:1)• 3‐5%ofERvisitsCCheadache,50%Tension,only8%potentiallyserious,and1%lifethreatening(SAH).

• PrimaryHeadache,SecondaryHeadache

WHATCAUSESAHEDACHE?• Inflammation– UnderlyingDisease,Sinus,Teeth,Meningitis

• Vascular– HBP,BloodFlowChanges

• Traction– Tumors,Abcesses

• MuscleContraction– MusclesoftheFace,Tension

• Hormones– Changes

• Vision‐ Limited

GENERALCOMMONHEADACHES

• Tension/Stress

• Migraine

• Cluster

• Sinus

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PRIMARYHEADACHE• Tension/Stress 69%

• Migraine 16%

• IdiopathicStabbing 2%

• Exertional 1%

• Cluster 0.189.0%

SECONDARYCAUSESOFHEADACHES

SymptomofanUnderlyingDisease• Hypertension Medication

• PostTraumatic Hematoma

• Dental Ear

• Hemorrhage Intracranialtumors

• Infections– Viral/Bacterial TrigeminalNeuralgia

• SinusInflammation Arteritis

• Glaucoma Withdrawal/Drugs

SECONDARYHEADACHE• Ofthe11%:• Systemic/Infection 63%• HeadInjury/Trauma/TBI 4%• Vasculardisorders 1%• SubarachnoidHemorrhage <1%• BrainTumor 0.1%• TrigeminalNeuralgia <0.01%• Other:SubstanceWD,Teeth,Ears,TMJ

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WORK

THEDOCTOR

THEDOCTOR

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YOURSIGNIFICANTOTHER

YOURSIGNIFICANTOTHER

ORNOT

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APPROACHTOHEADACHES• Location

• Timing

• Character

• AssociatedSymptoms

• Alleviating/Aggravating

• Enviromental/Setting

• PastmedicalHx

• FamilyHx

• SocialHx

• Sexual/SpiritualHx

• ReviewofSystems

LOCATION

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LOCATION• SITEANDSPREADOFTHEPAIN–Frontal–Temporal–Occipital–Unilateral/Bilateral–AroundEyes–BehindEyes–BaseofSkull

TIMING•Whyconsultingnow•Whenitbegan/Onset•Howlongdiditlast•Howmanytimesinthepast/FrequencyorPattern

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CHARACTER• Intensity/Severity•Quality• InterferewithActivities

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ASSOCIATEDSYMPTOMS• BlurryVision/NoVision

• Nausea,vomiting

• Dizziness,Diplopia,EyePain

• ENTproblems

• Dentalproblems

• Fever

• Anxietyordepressivesymptoms

• RaisedICP

ALLEVIATING/AGGRAVATING• Whatmakesitbetterandwhatmakesitworse• Painrelievers• Caffeine• Exercise/Activity• Cough• Cold/Heat• Touch

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ENVIRONMENT/SETTING• Whatwereyoudoing– ComputerWork– Eating– Drinking– Exercising

• Wherewereyouat

• Brightlightsordim

• Angry/Depressed/Happy/Calm

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PASTMEDICALHX• Allergies

• Hospitalizations

• Illnesses/Immunizations

• Surgeries

• Trauma

• Oralmedications

• Reproductivehistory/contraception

• Youthillnesses

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FAMILYHX• Genetic

• Otherswithsimilarproblems

• AliveorDeceased

• DeterminetheRiskFactors

SOCIALHX•HealthBehaviors• PersonalChoices•Smoking•Drugs•Drinking

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SEXUAL/SPIRITUAL• Medications

• Partners

• Practices

• ProtectionfromSTDs/PasthistoryofSTDs

• Preventionofpregnancy

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REVIEWOFSYSTEMS• Presenceorabsenceofsymptoms/Allsymptoms/Presentillness

• General Vision

• HeadandNeck(H&N) Pulmonary

• Cardiovascular(C/V) Gastrointestinal

• Genito‐Urinary Hematology/Oncology

• Ob/Gyn/Breast Neurological

• Endocrine InfectiousDiseases

• Musculoskeletal MentalHealth

• SkinandHair

TENSION/STRESS• MostCommonType!!!

• Frontofhead,temples,middle/topofhead

• Dull,achingandviselike,non‐pulsating– mildtomoderate.LikeaBandsqueezingthehead.

• Bilateralanddiffuse,worseatendoftheday.

• Nonauseaorvomiting.

• Occasionallydecreasedappetite,orphotophobia.

• NOTaggravatedbyphysicalactivity– willactuallyhelp.

• NOTattributedtoanotherdisorder.

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SYMPTOMSOFSTRESS• Anger LossofAppetite

• TensionandIrritability DifficultymakingDecisions

• Crying SleepProblems

• LossofInterestinActivity TroubleConcentrating

• Headaches,StomachPain FearandAnxiety

• SadnessandSymptomsofDepression

• IncreasedUseofAlcoholandDrugs

• DisbeliefandShock

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MIGRAINES• PainonOneorBothside(s)ofhead.

• Intense,pulsing,orthrobbing

• Canlastfordays

• Nauseaanddizzinessandlightsensitivity

• Flashinglightsandblindspots

• Commonlyrecurring

CAUSESOFMIGRAINES• ExactCauseisUnknownbuttheThinkingis:

• Resultofabnormalbrainactivityaffectingnervesignals,chemicals/hormonesandbloodvesselsinthebrain.

• Triggers:– Hormonal– Period,Serotonin– Emotional– Stress,Anxiety,Tension,Depression,Excitement– Physical– Tired,Posture,Exercise,LowBloodSugar– Dietary– Alcohol,Caffeine,SpecificFoods/Dairy,MissedMeals– Environmental– Brightlights,FlickeringScreens,StrongSmells,ChangesinWeather,Smoking,LoudNoises

– Medicinal– SleepingTabs,Contraceptive,HormoneReplacement

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MIGRAINESYMPTOMSANDSTAGES• Stage1– Prodrome:Beforethepainhits,50%ofsufferers– light/soundsensitivity,irritabilityandlackofappetite.

• Stage2– Aura:UptoONEhourbeforetheheadachewithchangesinvisualpercection orlossofvision.

• Stage3– Headache:ModeratetoSevereuptoTHREEdays,One/Bothsidesofhead

• Stage4– Postdrome:Severaldays,“hangover”,irritableandfatigued,moodchanges

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CLUSTER• Oneofthemostpainfultypes.Describedassharp,penetrating,orburning.

• Occursincyclicalpatternsorclusters.

• ExcruciatingpaininoraroundONEeye,droopingeyelid,excessivetearing,miotic pupil,andstuffy/runnynoseonthatside.

• Sensitivetolightandsound,Aura,Restlessness,palenesstoface,nausea,andexhaustionafterwards.

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SINUS• Inflammationoftheliningofeightsinuscavities.

• Facialpressure/pain‐ Frontaldeepchronicachearoundtheeyes,cheekbones,foreheadandbridgeofthenose.

• Leaningover,orsuddenmovement,orexercisingmaymaketheheadacheworse.

• Yelloworgreendischarge,paininupperteeth,badbreath,coughing,nasalcongestion.

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TRIGEMINALNEURALGIA• Sudden,Severe,unilateral,brief(fewseconds– twominutes),shocklike,usuallyconfinedtoonepartofonedivisionoftheTrigeminalNerveV(Damage).Rarelycrossesthemidline.

• PainParoxysms(sudden,violent)willreoccuroverdays,weeks,oryears.Periodsoftimewhensymptomfree.

• Sensitivetolightandsound.Nauseaandvomiting.

• Donotoccurduringsleep.

• Triggerareaonthefacewithslighttouch,wind,eatingorspeaking.

• SuicideDisease

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UNKNOWN/IDIOPATHIC

UNKNOWN/IDIOPATHIC•MigrainesareofunknownCauses• PainStructuresintheHead/BrainvrsNoPainStructures

•HavetotreattheSymptoms•Newdailypersistentheadache=NDPH

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THEEYES

THEEYES/OCULARCAUSESORSYMPTOMS

• Refractoryerrorandeyemuscleweakness– BinocularAbnormalities

Accommodation,convergenceinsufficiency,lackoffusionalcapacity– Musclecontraction– ciliary

• SecondarytoDiseasesoftheEye– Angleclosureglaucoma,iritis,keratitis,ocularischemicsyndrome,scleritis

• Systemicdisordershavingprominentocularsymptoms– RaisedIntracranialpressure,temporalarteritis,migraine,psychogenic

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BINOCULARVISIONDYSFUNCTION

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OCULARCONCERNS• Uveitis/scleritis PituitaryTumor

• GCA CranialNervePalsy

• OpticNeuritis Aneurysmorsah

• OrbitalTumor HighICP‐ papilledema

• OrbitalCellulitis CarotidischemiaandOIS

• Supraorbitalneuralgia Carotiddissections

• Chiarimalformation

“REDFLAG”HEADACHESYMPTOMS• SuddenOnsetorChange:Worst,WakingUp,Exertion– SAH,CerebralVenousSinusThrombosis,PituitaryApoplexy,Meningitis

• FocalNeurologicalSx:Seizure,Syncope,Conscious/Cognitive/Memory– IntracranialMassLesion,SAH

• ConstitutionalSx:WeightLoss,Malaise,Rash,Meningism– Neoplasm– Meningoencephalitis

• RaisedIntracranialPressure– IntracranialMassLesion

• NewOnset>60years– TemporalArteritis

SUPRAORBITALNEURALGIA/SWIMMERS/GOGGLE

• UnilateralPainintheForehead,Tinel’s Sign

• DuetolocationconfusedwithMigraine,Cluster,Sinus

• CausedbyDamageofNervebyTrauma,Pressure,Entrapment,Fluidretention,Eyeglasses.

• MayneedtoTreattheSupraTrochlearaswell.

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ORBITALCELLULITIS• Erythema,Edema,Tenderness,Fever,Warmth

• VisionChanges/Diplopia/LimitedEOM

• Ophthalmoplegia

• Proptosis

• Chemosis

• ReducedVisualAcuity

• AbnormalLightReflexes

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STAGINGOFORBITALCELLULITIS• I.Preseptal Eyelidswellinganderythema

• II.InflammatoryEdema Edema,Proptosis,Chemosis,DecreasedEOM

• III.Subperiosteal Abscess VisionLoss,Pus,SinusInvolved

• IV.OrbitalAbscess Ophthalmoplegia,VisionLoss

• V.CavernousSinusThrombosisDisplacement,Ophthalmoplegia,Beginningtoaffectothereye,CranialNerveinvolvement(III,IV,V,VI)

CHIARIMALFORMATIONTYPES

• I.FetalDevelopment– characterizedbydownwarddisplacementbymorethan4mm.ofthecerebellartonsilsbeneaththeforamenmagnumintothecervicalspinalcanal.

• II.DownwardDisplacementoftheMedulla,fourthventricleandcerebellum,aswellastheelongationoftheponsandfourthventricle.Myelomeningoceleexclusively.

• III.Cerebellum/Brainstempushingout.HighMortality– Rare–Severe.

• IV.SevereandRarest.ExtensiveMalformations.HighMortality.

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SYMPTOMSOFCHIARI MALFORMATION• OccipitalHeadacheatbaseofskull.Worsewhencoughing,sneezing,orstraining.Lookingdown/reading.

• Severeneckandheadpain.

• DoubleorBlurredVision.

• Lossofmusclestrengthinthehandsandarms.

• Collapsingtothegroundd/tmuscleweakness.

• Balanceproblems,dizziness,spasticity

• SensitivetoBrightlights.

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TREATMENTOPTIONSFORCHIARI• ReferraltoNeurologist

• 1.WaitandSee– IfMildornoSx,MRI’s,RegularCheckups

• 2.TreatEachSx Individually– NotsevereenoughforSurgery

• 3.Surgery– Sx Severeorgettingworse,Posteriorfossadecompression

SCLERITIS/UVEITISCLASSIFICATIONS• Episcleritis:SimpleandNodular

• Scleritis:DisturbsSleepwHeadacheandPain–Anterior:Diffuse,Nodular,Necrotizingbothwithandwithoutinflammation(perforancs)

• PosteriorScleritis/Uveitis‐ Uncommon

EPISCLERITIS• Blanchwithadrenergicagents

• Salmonpinkandmovablevessels

• MinimalPain

• Sectorial70%oftime.

• DoesnotProgress

• OralorTopicalNSAID’s,infrequentlySteroids

• 2/3Reoccurbutclears.

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SYSTEMICDISEASESASSOCIATEDWITHSCLERITIS

• RheumatoidArthritis– Rosacea– Chlamydia

• SystemicLupus– HSV– HSZ– Mumps

• Ankylosingspondylitis– Churg‐Strauss‐ Gout– Fungus

• Reiter’sSyndrome– Behcet’s – Parasites(Acanthamoeba)

• Psoriaticarthritis– IBS– GCA

• RelapsingPolychondritis – Cogan’sSyindrome

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MANAGEMENTOFSCLERITIS• ThisisanUrgentneedforreferralandTreatment.

• ReferralfortheOcularTreatmentisObvious

therestis:• DependentonUnderlyingMedicalCondition

• PosteriorScleritis isuncommon.– Fundusfindings:discswelling,macularedema,choroidalfolds,exudativeretinaldetachment,choroidaldetachments.

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ORBITALTUMORCFLASSIFICATION BYORIGIN• Primary– LesionsfromtheOrbitalTissues

• Conjunctiva,Sclera,EOM,Iris,Retina

• Secondary– LesionsfromtheNeighboringCavitiesandTissues

• Sinuses,Periosteum

• Metastatic– LesionsviaHematogenous orLymphaticSpreadfromotherareas.

• Breasts,Lungs

INCIDENCEANDEPIDEMOLOGY• Rare

• Male=Female

• Adults– MelanomaandLymphomamostcommon

• Children– RetinoblastomaandMedulloepitheliomamostcommon

• MetastasesaremorecommonthanPrimary– usuallyfromtheBreastorLungCancers

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PITUITARYTUMORSYNDROME

• OphthalmologicSigns– DecreasedVisualAcuity,VisualFieldDefects,Exophthalmos:Rare

• NeurologicSymptoms– Headache,Seizures,Meningealsigns,NervesIII,IV,VIwhichcrosstheCavernousSinus

• RadiologicalSigns– EnlargedSellaTurcica,Acromegaly

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OPTICNEURITISCLASSIFICATIONS• Retrobulbarneuritis – NormalDisc–Mostcommon,Demyelination– MS,Lyme,SinusRelated

• Papillitis – EdemaandHyperanemia–Uncommon‐ Syphilis

• Neuroretinitis – Papillitis andMacularStar–Cat‐scratchFever,Lyme,Syphilis

CHARACTERISTICSOFOPTICNEURITIS• InflammationoftheOpticNerve– PainwithEyeMovement

• SwellingoftheOpticNerveandEnlargementoftheBloodVessels

• VisionLossintheaffectedEyefromSlightBlurtoCompleteBlindness

• VisionLosscanbeTemporarybutPermanentinSomeCases.

• RAPD,LossofColorVision,FlashingLights

• HighlyAssociatedwithMultipleSclerosis

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TREATMENTFOROPTICNEURITIS• MostCasesImproveWithoutTreatment

• ToPreventtheRiskofMSIVSteroidsaregiven.

• IVSteroidscanalsospeedVisualRecoverybutcannotrestorelostVision.

• IfIVSteroidsdidnotworkandthereisVisionLossthenPlasmaExchangeTherapyistried.

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HIGHICP‐ PAPILLEDEMAMODIFIEDFRISEN SCALE

• Stage0– NormalOpticDisc

• Stage1‐ MinimalEdema– HaloSubtle,ObscureRetinalDetails

• Stage2– LowPapilledema– NasalElevation,NoVessels

• Stage3– ModeratePapilledema– ObscureFewVessels,Elevation

• Stage4– MarkedPapilledema– Obscurethedisc,FullElevation

• Stage5– SeverePapilledema– ObscureAllVesselonandleaving

• AlmostALWAYSBilateral!!!NoRAPDVF=EnlargedBlindspot.

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ARTERIC ANTERIORISCHEMICOPTICNEUROPATHYORGCA

• OVER50YO– CompleteVisionLoss,• Headache,VisionLoss,Diplopia,JawCaudification,Bruits,VF=AltitudinalDefect

• LossofVisionbydamagetoONd/tInsufficent BloodSupply,CRAO,CR

• Causeisunknownbutinvolvestheinflammationofsmallbloodvesselswithinthewallsoflargerarteries.MainlyNeckandHead.

• AssociatedwithHZV,RA,SLE,PMR• Dx:Symptoms,Medicalimaging,Biopsy,ElevatedESRandCRP• Tx:Steroids

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OCULAROBSERVATIONSOFAAION•DiffuseOpticNerveEdema•RetinalIschemia•CottonWoolSpots

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NON‐ARTERIC ISCHEMICOPTICNEUROPATHY• OVER50,MoreCommon

• SuddenLossofVision,MildPain,OftenBilateral,RAPD,VF=AltitudinalDefect

• CardiovascularRiskwith“crowded”OpticDiscs,AStroketotheOpticNerve,Hyperemic

• Visioncanimproveovertime.

• AssociatedwithDiabetes,Hypertension,SleepApnea,HighCholesterol

• Tx:Steroids

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ANEURYSMORSAH

• ThunderClapHeadache=WorstHeadacheinMyLife”

• PhotophobiaandVisualChanges

• NeckPain

• NauseaandVomiting

• LossofConsciences

• PastHx ofTraumaorBrainInjuryorLesions

• TearinSubarachnoidVeinsandCollectsUnderArachnoid.

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INTERNALCAROTIDARTERYDISSECTION• HeadacheTypicalFirstSymptom

• FaceandNeckPainPrecedeOtherSymptomsbyHours/Days

• PartialHorner’sSyndrome”Miosis andPtosis

• CranialNervePalsies

• CanMimicMigrainewithNauseaandVomitingandAura

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ACUTEANGLECLOSUREGLAUCOMA• SuddenHeadache

• VisualDisturbance

• SluggishPupil,MidDilated,HazyCornea,Redness,RaisedIOP,Papilledema

• IncreasedIOPcausingopticnervedamageinacharacteristicpatternthatcanpermanentlydamagevisionifleftuntreated.

FURTHERTESTINGANDREFERRAL

• CT Tumors,Nodes,Fractures

• MRI DetailedImagesofStructures,OrgansorSoftTissue

• MRA BloodFlowthroughArteries,Aneurysms,Malformations

• MRS ChemicalAnomaly,HIV,TIA,TBI,Tumors,MS,Alzheimers

• OCT,PHOTOS

•Recap

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