Headaches are the most common reason for consultation in neurology There are :
- Primary headaches
- 1 Migraine
- 2 Headache called "tension"
- 3 cluster headache and other trigeminal autonomous cephalalgias
- 4 Other primary headaches
- The secondary headaches
- Neuralgia and other headaches
I- INTRODUCTION :
- Migraine headache is a "primary", without underlying lesion, evolving by crisis.
- It is the most common headache with a prevalence between 10% -15%.
- Newbie usually between 30 – 40 years with a female preponderance.
II- PATHOPHYSIOLOGY :
L & rsquo; will Corresponds to a wave of depolarization that s & rsquo; extends by contiguity in cerebral gray matter causing blood flow changes (arterial vasoconstriction) resulting in a charge transient neuronal metabolic dysfunction symptoms of the & rsquo; will.
headache is caused by & rsquo; activation of the trigeminal vascular system that triggers the release of vasoactive neuropeptides causing arterial vasodilation and release of cytokines and mediators proinflammatory responsible headache
III- DIAGNOSTIC :
- The diagnosis is essentially Clinque
- Based on the criteria of & rsquo; international headache society (IHS)
- Distance of a crisis : when consulting diagnosis is mainly based on the & rsquo; interrogation.
On distingue :
– migraine without aura
– migraine with aura : typical, migraine familial hemiplegic, basilar migraine
1- MIGRAINE WITHOUT AURA :
- the most common (80%-90%).
- c & rsquo; is a self-limiting headache.
Semiotics of the crisis :
1- headache :
- moved gradually.
- n any time of day (the night, the morning)
- head in (2-4H)
- typically unilateral rocking
- topography : especially frontotemporal, sometimes occipital
- pulsatile nature.
- variable intensity even in the same subject
2- signs of & rsquo; accompaniment :
- nausea in 90% of cases, vomiting in 50% of cases
- phono phobia
- facial pallor, hypotension orthostatique, printing instability
DIAGNOSTIC CRITERIA OF MIGRAINE WITHOUT AURA UNDER(IHS) :
|A||At least five crises the criteria B-D.|
|B||headache attacks during 4 at 72 hours without treatment.|
|C||Headache having at least of them the following features :
|D||During headache, at least l & rsquo; a the following characters:
|E||At least a the following characters :
2- MIGRAINE WITH AURA TYPICAL:
- The headache is preceded or accompanied by & rsquo; an aura.
- transient focal neurological dysfunction, and fully reversible.
- progressive installation on over 5 minutes producing "migraine walking"
- duration between 5 min and 60 mn (average 30 mn).
Typical get selected by I S H are:
1- bilateral visual disturbances (two eyes) : scotomes scintillants, phosphènes, blurred vision.
2- sensory : numbness or paresthesia unilateral.
3- Language disorders : aphasia or language difficulties.
Diagnosis is based on the presence of at least two attacks fulfilling the criteria diagnosis of migraine with typical aura as I’ (IHS).
IV- COMPLICATIONS OF HEADACHE :
- Chronic migraine : the headaches last for more 15 days / month for more than 3 month.
- State migraine evil : Continuing crisis beyond 72 hours.
- L & rsquo; infarction migraine : Very rare, Evoked when & rsquo; will typically lasts more 1 hour. Diagnosis is based on neuroimaging shows a hypodense corresponding to the & rsquo; infarction
- Crisis & rsquo; epilepsy triggered by a migraine aura
V- TRIGGERS A CRISIS OF HEADACHE :
- psychological factors : anxiety, emotion, psychological shock
- hormonal factors : rules, oral contraceptives
- Changing lifestyle : move, job change, vacation, voyage
- sensory factors : light, noise, odour, vibrations…
- Food : alcohol, chocolat, fat baked, cheese, citrus
- climatic factors : Vent, heat, cold
- Eating habits : fasting hypoglycemia, skipped meals
- THE FACTORS AGGRAVATING : – Head movement, cough, physical effort
- RELIEVING THE FACTORS : – Rest, Eye closure, Calm, l & rsquo; darkness
WE- TREATMENT :
1- TREATMENT OF THE CRISIS :
Prescribed from the start of the crisis to limit the & rsquo; intensity and duration of migraine headache.
- Anti inflammatory drugs (AINS) : ketoprofè knot, acetylsalicylic acid, Ibuprofen, diclofé nac. Can be taken from the & rsquo; will
- Les Triptans :
eg Sumatriptan : 100cp mg to 50mg , spray 10-20mg,
injection sc 6mg
Taken at the time of the headache and not the aura
Cl : ischemic heart disease, Vascular diseases, HTA
- If & rsquo; monotherapy failure association & rsquo; an NSAID and & rsquo; a triptan
- the analgesics (Paracetamol) are avoided because of the risk of headache induced by abuse of medication.
- Derivatives & rsquo; ergot : In the final plan
– la Dihydroergotamine (AND) IM, IV, SC
– Gynergène caffeinated
- adjuvant treatment : antiemetics, anxiolytics
2- BACKGROUND TREATMENT :
Aims to reduce seizures
– if the crisis frequency is more than 3 / month
– spaced but severe crises, embarrassing the patient's quality of life
– if the patient is a treatment crisis over 2jrs week
- Effective : if seizure reduction of 50%
- Tricyclic anti depressants (Amitriptyline)
- Anti-inflammatory drugs,
- Topiramate (Anti Epileptique)
- Valproate de sodium
– If correct answer duration of treatment is a Omois 1 year and very gradual decrease before stopping treatment.
– In case of failure :
+ Increase dosage, in the absence of adverse effects
+ or suggest another background TRT
This is a facial pain whose topography is one or several areas of the branches of the fifth cranial nerve : the ophthalmic nerve Willis (WE), nerve maxillary (V2), lejierf mandibular (V3)
I- DIAGNOSTIC :
1 – essential neuralgia V (Disease Keychain) :
pain : intense (electrical sensation, stab)
– Paroxysmal occurs in short term bursts of a few seconds has 2 minutes with free interval pain that lasts a few minutes to a few hours
– unilateral, always strictly localized to the territory of the trigeminal
– at the peak of pain, muscle tremors or clonic grimaces of the face may occur, performing the "tic".
– caused by the & rsquo; d & rsquo touch; one or more trigger points
– no neurological examination is normal neurological deficit
2- symptomatic neuralgia (secondary) you v :
– The pain is continuous, n & rsquo; is not triggered by the peripheral stimuli ; about young (before 50 years)
– often immediately reached several branches.
– reduction or abolition of corneal reflex, or attainment of motor quota.
etiologies: SEP, neuroma & rsquo; acoustic, meningioma, zona you ganglion de Gasser, tumors of the base of the skull, diabetes…
II- TREATMENT :
– carbamazepine (Tégrétol®) : first line therapy at a dose of 600 a 1 800 mg.
A good response constitutes a diagnostic test t.
– new antiepileptic : if intolerance to carbamazepine
Gabapentine, Prégabatine, Topiramate Lamotrigine,levetiracetam
surgical treatment : If medical treatment fails
1- Vascular microsurgical decompression of the V nerve
2- Thermo trigeminal ganglion percutaneous coagulation
VASCULAR ALGIE FACE (AVF) :
L & rsquo; cluster headache is a primary headache lot rarer than migraine with a male predominance.
The early average age is 28years.
I- POSITIVE DIAGNOSIS :
- Extremely severe pain., continue
- a type of burn, feeling heartbreak, d & rsquo; crushing
- Strictly unilateral always touching the same side, predominantly orbital.
- Evolving by daily crises over to 15 at 180 minutes, occurring on average one to three times per day.
Symptoms associated : sit on the side of pain
- conjunctival injection, lacrimation, rhinorrhea and nasal congestion.
- myosis, ptosis.
- nausea, vomiting, phonophobie, photophobie
- sweating or redness of the & rsquo; hemiface
- eyelid edema
Apart crisis, l & rsquo; neurological examination was normal
II- TREATMENT :
1- TREATMENT OF CRISIS :
- first-line: injectable sumatriptan subcutaneous
- if cons-indication or very frequent seizures : l & rsquo; hyperbaric oxygen at a rate of 7 a 10 liters per minute for 15 a 30 minutes
2- BACKGROUND TREATMENT :
- first-line: Verapamil
- second intention:
– Corticosteroids or methysergide
3- SURGICAL TREATMENTS :
If resistance to all drug treatments
Course of Dr H. SEMRA – Faculty of Constantine