Headaches and cluster headaches

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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

HEADACHE

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
  • photophobia
  • 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 :

  • unilateral.
  • Pulsatile.
  • Moderate or severe.
  • Aggravated by routine physical effort (to go upstairs).
D During headache, at least l & rsquo; a the following characters:

  • Nausea and / or vomiting.
  • Photophobia and phono phobia.
E At least a the following characters :

  • The story, l & rsquo; physical and neurological examination do not suggest organic disorder
  • Or the latter is removed by neuroimaging or other laboratory process.
  • Or an organic disorder exists but migraine attacks did not appear for the first time in temporal association with it.

2- MIGRAINE WITH AURA TYPICAL:

  • The headache is preceded or accompanied by & rsquo; an aura.

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

  • Indications:

– 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%

– pharmaceuticals:

  • B-blockers,
  • Anti-serotonergic,
  • Tricyclic anti depressants (Amitriptyline)
  • Anti-inflammatory drugs,
  • AND,
  • 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

Trigeminal neuralgia

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
– diphenylhydantoin
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
– Lithium

3- SURGICAL TREATMENTS :

If resistance to all drug treatments

Course of Dr H. SEMRA – Faculty of Constantine