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Hello. Uh I'm a No. Hello. Ok. I hope everyone else can hear me. Uh let's uh move on to the session. So today our topic will be on about headache. So moving on, uh talking about headache. Now, when a patient presents to you with headache, there are certain things when our first uh interaction would be taking a history from the patient, right? So when talking about headache, it is a very common symptom where multiple patients present you with this uh condition. So uh I'm talking about the headache uh taking the history. Uh There are certain things uh certain points in the history which uh we would like to have to come to come to a particular differentials when moving on with our history. So in this history, we would like to have the onset. That is when did this headache start the distribution where all this headache is distributed, uh the duration of this headache episode, any frequency of episodes, the frequency of this particular episode. And uh we also would like to have uh in the history, any sinister features that is any associated features that is coming with this headache. So these can help us uh identify any other particular sinister causes for this headache. There is any secondary causes. So these sinister features can be uh these can be due to a raised intracranial pressure or it can be uh meningitis. So I would like to ask you a question. Uh How, what, what are the features of a raised intracranial pressure? You can uh may take out in the history. I type this question. Yes, yes, doctor. We can see uh features. We can see, we see early morning headache that is early morning headache with the vomiting. And we also we can see this uh headache increases with straining. And also we can see other neurological signs such as any weaknesses of the blurred vision. Yes, just doctor. And we can see early morning headache with vomiting and that increased draining with vomiting and other neurological signs. As papilledema is uh we cannot assess with, with the exam history. We should do an examination with the fundoscopic is pap edema. Ok. Thank you. And also we have many uh meningitis. Uh that is also another cause of the headache which we should exclude. So, uh can you name some of it is the meningitis which you can uh assist in this history. Uh Sorry. Uh the treat you have meningitis, which you can assist in was my question. I have uh I have put the pressure in the chat box. Yes. Uh Do thank you. Uh in the history we can assess there this high uh uh uh high fever. And also we can see neck stiffness, patient presents these to uh moving on to the other part of the history. We also should ask for any other history of trauma because this headache can be due to a subdural hemorrhage or conditions like that or this visual impairment which can be caused on about. Uh uh yes. Uh yes also and uh other visual impairment features due to g arthritis or temporal arthritis. Uh if there's any disability, if there's any treatment done after to now, and the response to treatment, the patient presented this symptom early. Also, we should ask for the treatment done after now. So these are the components which we should assess in the history of the patient with taking a headache history. Uh Now, moving on, let's uh move on about our session today. So that's what our session today is talking about the primary headache. That is a primary headache. That is the illness. Uh headache is the the headache which the it which is the illness itself. So here we have 10 to head and the head uh secondary headaches. Uh du the second head occur when the patient is underlying illness. That can be sometimes uh uh sist can cause sist headaches. So it can be due to another uh life-threatening reasons. So, those are secondary headaches. Now, uh moving on about your primary headaches. Uh We have uh first of all we have a tension type headache. So we talking about tension type headache. This is a dull headache which often occurs uh when the patient is undergoing serious stress or the patient is uh under uh chronic stress. So this uh the internal headache society, this is the, so IH is a society which uh which uh which classifies and defines all these headaches and uh associated features. So that uh state this headache here is stated as uh episodic that can be frequent infrequent or can be chronic. So, episodic is when the headache is usually mild and it responds to these over the counter medications such as the A NSA. So can these are nonprescription drugs? So it occurs less than one day a month, is infrequent frequencies. It it is frequent if it occurs 1 to 14 days in a month. Chronic is if the headache occurs 15 days uh or more. And in the occurrences it is more common in females than males so that we should know. And uh when you talk about the diagnostic criteria given by this uh International Headache Society, we have it uh pain should be a pressing or tightening pain, it should be in the front occipital location. It should be bilateral and also it should not be aggravated with physical activity. So specifically talking about this headache, which I have uh put in a clear of detail format here. So the duration of this headache should be around 30 minutes of headaches with it has no associated features such as what I mentioned, there is no, there is no associated nausea or vomiting or photophobias or phonophobia. There are no associated features with this headache. This is a very benign headache. It occurs in regular lot of people. And this uh we talk about the pain location. It is a bifrontal, it can occur in the occipital nu that behind the head or it is a bi bifrontal. And this pain uh the patients describe this pain as like a band like pain. When they place this band on top of the head, it's like a pressing band, fighting pain, band like pain on bi uh bifrontal in the bifrontal area. And there's uh also other feature which you can find this tension type headache is we can uh find that this uh headache has a neck stiffness, also can make stiffness of these muscles in the neck area. So talk associated features. And as I mentioned earlier, there is no uh associated features or there is no Prothro features. Uh management of this condition is uh very simple. It can use reassurance because uh once the stress which causes this condition such as uh work stress or can be uh they didn't have enough sleep for the patient or can be other stresses. Once the stress is gone, the patient can uh this uh head will improve or we can take over the count me such as this acetaminophen, NSA tricyclic antidepressants are dose, which can be used but not very important stress management, which is very important for this uh exercise, hot or cold packs, electrical stimulation. And this occipital nerve blocks are done. It is chronic headache and it's continuously uh affecting the patient's day to day life. We can go for this uh these management techniques, but it's not commonly used. We use this reassurance, Medicare, uh acetaminophen stress management posture improvement. These are more commonly used in this condition. Uh Moving on. Now, let's uh talk about the cluster headache. Now, cluster headache is a a type of headache. Uh as defined by the the IHS is when there's a severe unilateral pain that is around the orbital area which lasts for 1580 minutes. And this this cluster attack is associated with uh uh associated with some uh features such as this conjunctive injection, lacri information and uh rhinorrhea meiosis. It's uh the retro this uh orbital area that is involved. It is associated other features associated with that area access, severe rhinorrhea, conjunction injection is I meiosis PSIS eyelid, all is associated with that affected orbital areas. Now, this uh cluster headache is uh it is divided in two parts. We have the episodic cluster headache and uh this chronic cluster headache. So, episodic cluster headache is when there's two class two cluster phases. So what do, how do you define cluster cluster phases when there's a duration of around several weeks or months during which this uh cluster headache regularly occurs at least uh at least once every other day. That is once in every two days. That's a minimum. This occurs this cluster headaches. So this uh when it occurs during several weeks or months, we call that pi in the cluster phase. The chronic cluster head uh cluster headache is when this cluster headaches occur for one year or longer with all this remission period or this remission period is less than three months. So that is when you call it as chronic cluster headache. Now, the occurrence of this cluster headache is more common in uh males than females. This uh only headache common in males is cluster headache. So as you can see uh this uh patients, they will complain like uh all patients or patients partners or people who are sleeping with, they will complain. The uh male patient will get up uh in the during the midnight or they uh while sleeping and they will hold their eye and they will wait. This is a common presently complain in uh patients who have discuss the headache. It occurs most in patients 20 to thirties or forties. Now, uh the talk about the cost is not thoroughly understood. There are risk factors that can be triggers or risk factors. So this can be tobacco use alcohol, histamine, seasonal fluctuations, nitroglycerin or what type substances such as oil based pain. These can cause uh triggers constant headache. Now, uh we talk about this cluster headache, it particular uh as I mentioned before, it occurs during sleep on the early morning hours. And it is associated a re part of the sleep because uh the sleep is divided into two parts rem sleep and non sleep is ren sleep is rapid eye movement sleep. Now, we talk about the pain of this cluster headache that this is a retro pain. I as I mentioned, it is locations retro area. It is an exclusion. It's a stabbing exclusion. This is a severe pain where patient complains, it is like stabbing as the eye is being pushed out. This is how the patient complains it and it is uh associated in the perio retro temporal regions of the area. But sometimes this pain can radiate to the other associated areas. So the jaw, uh cheek occipital areas. Now, the distribution of this pain is uh like the 1st and 2nd divisions, the trigeminal, this is uh the the forehead area and the retro area part of the maxillary area. So, and it uh sudden on, it has a sudden onset which goes to peak pain 10 to 15 minutes and it can last for five minutes to uh three hours per episode after you can re it. And it uh now we talk about the remission of this condition. It uh after this particular episode occurs, there is a long symptom free period during which the patient has no symptoms. And after that, the patient can uh again get this particular cluster uh headaches. So if this occurs during a a repeating attacks occurring during a set of time period, that is called a cluster uh of the face. As I mentioned earlier, uh we talk about management of this cluster headaches. So management of cluster headaches, it you it is divided into two parts. We have this abortive therapy and preventive therapy. Aborted abortive therapy is when the patient is having an acute attack. This abortive therapy is given to reduce or reduce the attack or stop the attack. Now, preventive therapy, it is given to reduce the frequency. The number of times the attack is a reduce the frequency and the intensity of individual attacks. So what we do is we start this preventive therapy. When the uh if we can take the proper history of the patient, we can identify particular citic cycles. So we start this preventive therapy at the start of this cycle and we should continue, continue this therapy during the cycle also until the patients headache free for at least two weeks. Now, this aortic uh aortic therapy. The first-line management is this oxygen therapy that is we give around eight liters per minute for 10 minutes or 100% oxygen given by mask. This oxygen therapy is a first-line management for cluster headaches in patients. Other managements, we can give these five hydroxytryptamine uh which are Triptan. So they can be a good uh a good alkaline. This is given with MethylPro. So these uh Triptans, they produce uh direct vasoconstricting effect, constricting the vessels which cause this cluster headache towards the rebill area and they can abort the attack. Uh other medications we can give subcu of uh the sumatriptan. As I mentioned earlier, Triptan suffers uh sumatriptan. So the dose is around six mg subcutaneously and it is repeated 20 repeated every 24 hours. Nowadays, there is intranasally, this nasal spray around 20 mg of the sumatriptan which can be administered. Studies have found that this uh intranasal administration more effective than placebo but is not effective injection. So this intranasal can be used in patients if needed but injections have a better Effe uh effectiveness. Another medication that uh that is being used to your di other options. Yeah, ergot lie octreotide. Also a short course of steroids also is being used but uh studies have not shown it properly. But there are studies where short course of uh a short course of steroids also has been used for about the therapy of cu the headaches moving on. That is uh talking about preventive uh preventive methods. So in preventive methods, calcium channel blockers, that is mostly verapamil, that is the most effective is verapamil is a non dip calci channel blockers is the most effective and compare other calcium blockers to prevent these attacks. Now, if your patient is not tolerating the verapamil or it is ineffective. We can go on with a melatonin or the emergent therapies such as Galca Zuma. Right now, this can be stopped off these uh drugs. These drugs can be stopped after the episodic uh cluster headache period has ceased. Or if it is uh if the patient is having chronic cluster headache, you should be continued for long term. As I mentioned earlier, the patient should be headachefree for at least two weeks for to stop this attack. Uh corticosteroids also, as I mentioned, are being used here to determine this cas cycle. So, corticosteroids also being uh used here. Now, another uh method of uh management is neuromodulation or neuromodulation. It is used only if the patient is not really not uh managed by these medical therapies as I mentioned earlier. So in neuromodulation, we have noninvasive invasive methods, noninvasive example, we have noninvasive vagus nerve stimulation that patient can uh use a handheld device and control it. And they, they should be told they have give it for three consecutive two minutes, they should be given for three consecutive two minutes stimulation twice a day. Invasive methods. We have a spinal and ganglion stimulation where the patient where the device is uh surgically implanted in the the fossa. So the patient is, if the patient is having chronic cluster headache, the patient can activate this device uh which which will provide pain reef. Also another method is uh occipital nerve stimulation. So these are the two types of neuromodulation, which are used when the patient is not, uh patients, pain cannot be controlled by the medica uh medications alone. Uh Yeah. So those are the two methods, please, please. Uh please uh don't be hesitant to ask any questions. Now, moving on migraine now, migraine is uh one of the biggest and most important topic we have been talking about this uh primary headaches. Now, uh when you talk about migraine, it is a complex, it is a complex disorder because it can be associated with multiple other conditions also. So this is a very complex disorder. It can be uh isolated or it can be associated. So, um what how do we define migraine? Migraine is uh in migraine. What do you see is a recurrent episodes of headache which is mostly lateral and is associated uh Visar sensory symptoms. You see these visual sensory symptoms, they are known as an aura. This arise uh when you talk about aura, this aura, I will talk about it more with the the next few slides. So simple definition, this aura is something that this visual sensory symptoms that occur before the headache that is called aura is migraine is more common in females and it is uh mostly occurs in adolescent, early adult life. And there there's a family history which you can ask the, which you can uh ask the patient. I talk about the etiology or risk factors. There's a genetic predisposition I, as I mentioned earlier, there's a family history. So there's a genetic predisposition to for the patient to have these migraines and other triggers are including certain foods and beverages, alcohol, nicotine, citrus foods, dairy products, or thymine containing foods. So, the patient is fasting or dehydrated, poor sleeping habits, emotional stress, weather changes, hope no changes in women such as menstruation, oral contraceptive, these OCPs, this all can trigger the migraine this patient. So we should always assess these conditions if the patient has any of these uh in the history before the patient uh has a migraine attack. Now, when we talk about the migraine, now the migraine attacks can occur without aura or it can occur with the aura. So without the aura is uh most common but with the aura, it occurs in around 25% of the patients. Now, the, you know, we talk about typical migraine attack. A typical migraine attack has four phases which uh which is uh including the aura which occurs uh as I mentioned, occurs with a headache. So we talk about four days of a typical migraine, the pro period. Now this prodrome period occurs 24 to 48 hours before the headache. So here we can see uh there can be excessive yawning or the patient can have difficulty in writing or reading or there's a sudden hunger or lack of appetite or mood changes. These are very nonspecific symptoms. The patient can get in 24 to 40,000 for the headache, moving on after the period with the aura. So this aura day last 5 to 20 minutes uh before the headache starts and it lasts 60 minutes. These auras, these auras can be a typical aura that is we have visual disturbances, sensory speech symptoms or they can be atypical symptoms. Now, we talk about the typical aura, we can see that uh these visual disturbances, the patient can uh tell they have uh uh skin gating scotomas. So this is when there's an R shift scotoma, uh scotoma, it's an area of uh area visual defect that the patient can't see anything. So the scotoma uh starts skin scotoma. They are uh ar scotoma starts centrally and then it slowly moves to the periphery and then we have central scotoma. There can be flashing lights. The patient can say they have flashing lights or they cannot see color properly or we can see a for spectra that is stars, exact figures or star like figures, sensory deficits or parasthesia, abnormal sensation. So, yeah, uh what you can see in this uh what you can see here, this is a central scotoma. You can see a central defect where the patient is seeing. So this uh skin clear scotoma, as we mentioned here, he's uh it's when the scotoma starts centrally and then it goes to the periphery that is a scintillating scotoma. What we can see here is the fortification spectra men that you can see these exact lines. The patient can complain of these before the onset of this other severe migraine attack, severe headache, severe headache, and then there are uh no more symptoms and they, these go gradually and last less than 60 minutes, atypical aura. When a patient does any, that is when there is there difficulty or weakness of moving the arms and legs, there can be dizziness. Uh these symptoms can be persistent. Uh We talk about the headache. When we talk about the headache associated with migraines, it is a throbbing up pulsatile headaches. Now, as I mentioned in my uh cluster headache was it was a stabbing or severe headache. But in migraine, we are throbbing up pulsatile headache, which uh goes from moderate to severe pain, it intensifies the movement of physical activity. So when you talk about the location of the headache, it can be unilateral headache in the fronto temporal area area, but this pain so you can feel around the head. Sometimes there's uh some occurrences of bilateral migraine attacks that is uh pain occurring in both of the both sides of the head. But more commonly, we have unilateral pain in the frontotemporal area. Now, the pain slowly increases in 1 to 2 hours and it lasts for around 4 to 72 hours. Um migraine is associated with other features associated features. We have nausea, vomiting, anorexia and food tolerance and lightheadedness. And they have this photophobia as well as phonophobia. So these are associates we know just specific for migraine. These features are not there in in cluster headaches or tension headaches in class. As I mentioned earlier, they have what associate features we have these uh conjunctive injections, rhinorrhea, meiosis features like that in migraine attacks, we have this nausea, vomiting, uh phonophobia, photophobia and after attack, the patient can feel exhausted or euphoric. They have muscle weakness, they can have uh other an foot features. Now, moving on and talking to investigations now for migraine, it is usually a clinical diagnosis can be made for the patient, but we should always be aware because there can be other sinister cause other causes which can lead to this migraine. So newer imaging should be done. If you, if you suspect a sinister cause, we should always go for neur imaging. There is an MRI should be done or lumbar puncture. So, indications for neuroimaging in the patient person, migraine, we should always be uh I ask the patient if it was the first or the worst ever headache we have seen in their life. If there is a change in the pattern of previous migraines, which will become more frequently if there's an abnormal neurological exam. If the onset, the first time of the migraine occurs in patients after 50 years. If it is a nuance headache in an immunocompromised patient, or if the patient presents with migraine along with an epilepsy, or if there is a increase in the intensity and frequency of the head attacks and the uh migraine attack is located in the posterior head. So these are indications for imaging it MRI uh which should be uh assessed in the patients. All these features should be always be uh ready for these features because this can kill the patient. Uh We can talk about the management of uh migraine index. Uh the acute treatment, the acute treatment in the patient presents with migraine, you treat them immediately immediately. That is to stop or at least reverse the uh progression of the headache that I started. Then a preventive treatment. The preventive treatment is given in the patient does not have a headache and it is done to reduce the frequency and severity of the attack. Now, uh when treating a migraine, we should also screen the patient for any cardiovascular risk factors and they, they should be treated aggressively, hypertension, they should treat aggressively. And if migraine is are presented aura, they should also be counseled because uh migraines who present present aura, they have increased risk studies have shown they have an increased risk of stroke with or smoking, oral contraceptive use. So they should be counseled to decrease or reduce or stop the using of this usage of this. Now, now we're talking about the management of uh an acute migraine, the management of acute migraines. The first treatment of in as ibuprofen, acetaminophen aspirin or any of the combination including caffeine and also the add a pro or do these are the first line drug used in an acute migraine attack. Also another this migraine specific agent, this uh Triptan sumatriptan ergotamine. These also can be used as the first and for a attack. You should not combine these, as I mentioned here, you should not combine this Triptan ergotamine, you should give either one of these attack. So examples, we have oral tan. If uh if a patient is tolerating orally, we can give this or Sumatriptan or Sumatriptan amit Triptan. Now these work best when taken early and also they are not useful if the patient has already started the headache, these these treatments are not useful. So they should be taken before the headache has started and they are contraindicated. This uh treatments are contraindicated. Patient has cardiovascular diseases in coronary artery diseases. If they have uncontrolled, such as the uh this cardiovascular, uh as I mentioned here, the patient is a cardiac risk factor, they should be treated right. So these uh if you uh they should not be given to the patient, these treatments should not be given if the patient has those particular car risk factors. And uh if the patient is nausea or vomiting or he has a high analgesic drink, we can use Sumatriptan or ZOLMitriptan second line drugs. As I shown here is uh al other drugs can that can be used uh are parenteral anti drugs such as metoclopramide, chlorine, Diphen, these are second line drugs that can be used uh prophylaxis prophylaxis as all preventative therapy. It is indicated the patient is having migraine attacks for more than two per month and the duration is more than 24 hours. And the headaches causes major disruptions in the patient's lifestyle every day. These migraines are uh affecting him. And if it abortive therapy, this uh pre preventive therapy, as I'm gonna mention after, if this, the therapy fails, we should go for this prophylactic therapy. And obviously, if this, uh, medications are contraindicated or ineffective or if the patient uses a body medication more than one, twice a week. So we talk about the prophylactic medications used. We have beta blockers, tricyclic antidepressants, calci channel blockers, two antagonist, these anti drugs, angio receptor blockers. So, the patient should be properly assessed before giving these, uh prophylactic drugs. And also we should check the patients having a drug allergies and all because we preparing for that. And after 6 to 12 months of this prophylactic drug is given, we should withdraw these drugs, uh, withdrawal, withdrawal of these drugs should be considered in patient. Mhm.