NEUROLOGY, MED II - 3RD YEAR
- (-) Fever
HEADACHE
(DR RABO – TRANS by PRETTYVEGANDUGMISSALMONDMILK,
PREPARED by CAYRAPF,
MIDTERMS February 2017)
 2 Types of Headaches:
1) Primary Headaches
- No known cause
2) Secondary Headaches
- There is a cause (it’s secondary to something), It is
present because of another condition.
- (ex.) Headache because of a tumor
- In elderly, don’t think of primary headache agad.
You always have to think of secondary before
primary.
 The 1st thing you should do is get a comprehensive,
detailed & extensive HISTORY (from the history
malalaman mo na yung mga RED FLAG signs.
 RED FLAG SIGNS OF HEADACHE
- Will point out that it is secondary headache
- Sudden in onset
- (SUDDEN SEVERE headache then nag VOMIT, una
mong iisipin is ARACHNOID HEMORRHAGE
- Severe
- FIRST SEVERE HEADACHEA
- Anything with accompanying fever (systemic)
- *READ MORE OF RED FLAG SIGNS ON HARRISON’S*
(TABLE 21-2) HEADACHE SYMPTOMS THAT SUGGEST A SERIOUS
UNDERLYING DISORDER, p. 108 Harrison’s 19th Edition
- Sudden-onset headache
- First severe headache
- “Worst” headache ever
- Vomiting that precedes headache
- Subacute worsening over days or weeks
- Pain induced by bending, lifting, cough
- Pain that disturbs sleep or presents immediately upon
awakening
- Known systemic illness
- Onset after age 55
- Fever or unexplained systemic signs
- Abnormal neurologic examination
- Pain associated with local tenderness, e.g., region of
temporal artery
 After History → P.E. → Neuro Exam
 CASE: 30 years old, Male, came in because of severe
headache with vomiting after playing basketball. In
the ER, patient is still complaining of headache.
- MENTAL STATUS: Normal, GCS 15, Can calculate
- (+) Diplopia – Check extraocular muscles
- EOM full and equal
- MMT 5/5 on all extremities
- Normotonic
- Reflexes +3 on both upper & lower extremities
- Pupils: Isocoric, 3mm, bilaterally briskly reactive to
light
- Not taking any medications prior to attack, but is
taking Paracetamol once in a while if he
experienced headache
- (+) Kernig’s
- (+) Brudzinski
- No dysmentia
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- (-) Dysdiadochokinesia
- DIAGNOSIS: SECONDARY HEADACHE: CHEMICAL
TYPE (SUBARACHNOID HEMORRHAGE)
 No fever
 (+) meningeal signs
 Young patient, sudden severe onset
PRIMARY HEADACHE
 CT scan (to rule out other cause)
 No test will tell you it’s migraine, tension
 No lab test will point out primary headache, as long
as you fulfill the criteria for migraine, no red flag signs
& normal neuro exam → primary headache (based
on History & P.E)
 Pattern-based
 Migraine, Tension or Cluster Headache
PAIN SENSITIVE STRUCTURES
 Blood vessels, nerves
 Skin, subcutaneous tissue, muscles, extracranial
arteries & periosteum of the skull
 Intracranial venous sinuses & their large tributaries,
MED II, NEUROLOGY - JANUARY 2017, 2ND SEMESTER
especially pericavernous structures
 Delicate structures of the eye, ear, nasal cavities, &
paranasal sinuses
 Parts of the dura at the base of the brain & the
arteries within the dura, particularly the proximal parts
of the anterior & middle cerebral arteries & the
intracranial segment of the internal carotid artery
 Middle meningeal & superficial temporal arteries
 Optic, Oculomotor, Trigeminal, Glossopharyngeal,
Vagus & 1st 3 Cervical Nerves.
NON PAIN SENSITIVE
 Pia, arachnoid & Dura over the convexity of the brain
 Parenchyma of Brain (That’s why there is awake brain
surgery)
 Ependyma & choroid plexus
 Brain
MECHANISM OF HEADACHE
1. DEFORMATION OF THE BLOOD VESSELS
 If there is tumor, if you have something there in your
brain that stretches your blood vessels, as well as your
nerves, it will cause headache because blood vessels
are sensitive
2. INFLAMMATION
 (ex.) Meningitis
3. PRESSURE FROM OBSTRUCTION
 (ex.) ↑ ICP
 Generalized edema of brain → You see this in patient
with Hypoxic Encephalopathy, nagkaroon ng
destruction of brain because of poor blood flow
 Those with sodium problem (cellular swelling)
↓
Generalized Edema of the brain
↓
HEADACHE
 Yung obstruction is usually secondary to
Hydrocephalus (Obstructing type)
NON COMMUNICATING HYDROCEPHALUS disappear & then appear at an older age pero
Obstruction may be in the: nagsisimula sila ng bata!
 3rd ventricle  Ubiquitous family history (Prevalent in the family,
 4th ventricle heredofamilial disease)
 Lateral Ventricle  Can be accompanied by nausea & vomiting
 Foramen of Magendie  A typical migraine attack is not tolerable (meaning di
 Foramen of Lushka kaya pumasok, di natitiis, masakit na masakit,
patients prefer to sleep)
COMMUNICATING HYDROCEPHALUS  Management: Avoid/refrain from doing things that
Obstruction may be in the: will trigger the Migraine
 Arachnoid Granulation or Pacchionian Bodies  Same treatment with Migraine with aura and without
 Problem in resorption of CSF fluid → GEN. aura
HYDROCEPHALUS  Why do you have to know if with aura or without
 Aqueduct of Syvius → Lateral Ventricle → NON- aura?
COMMUNICATING  Kasi pag may aura mas madali sabihin na migraine
nga siya & in the treatment, mas madali gamutin
PRIMARY HEADACHES yung may aura kasi may warning sign siya. Give the
MIGRAINE pain meds during the aura kasi pag nagmimigrane
 Epidemiology: More common in women nay an pwede magvomit, edi navomit niya lang
 MIGRAINE – vascular headache yung gamut. So give it during aura phase.
 Lateral – UNILATERAL (one-sided) THROBBING PAIN  Treatment: avoid triggers
- Catch menial migraine (menstruation)

MED II, NEUROLOGY - JANUARY 2017, 2ND SEMESTER

 Can occur with or without aura
 Without aura is more common - Food (MSG-containing): always ask for the DIET!
 Mechanism:  Pharmacologic:
 Bakit ka nagkaka aura sa migraine? Aura is a 1. ABORTIVE THERAPY
neurologic symptom (This will tell you na after 15 - Para mawala sakit ng ulo, to relieve the
minutes magkaka migraine ka na, it’s a PRODROME headache
SYMPTOM) like a warning sign. 2. PROPHYLACTIC THERAPY
 It can be visual, smell, numbness, sensory, motor, - Take it even without the headache to prevent
auditory. But the most common is visual. It can be recurrence of headache, or to decrease
anything depending on which part of the brain is frequency, intensity or severity of the pain
affected. ABORTIVE PROPHYLACTIC
 In vascular theory, aura is because of - Celebrex - Sibelium
VASOCONSTRICTION - Arcoxia (COX2 inhibitor) - Antidepressant
↓ - Celecoxib - Anti convulsant
Ischemia - Paracetamol (preferred)
↓ - Tramadol Ex. of anti-convulsant:
Aura (Parang deficit) - Ibuprofen - Gabapentin: not usually
↓ - NSAID given, sedating, no
VASODILATION – compensatory evidence for migraine
↓ prophylaxis, more for
HEADACHE neuropathic pain
 Before (but was never proven) migraine and stroke - Valproic & Topiramate –
are connected. If you look at MRI, MRIs of patients usually given. Valproic
with mild, frequent, migraine attack may mga can make you fat.
ischemic changes sa mga blood vessels (abnormal Topiramate, slimmer and
unidentified bright objects on MRI!) make sure no Glaucoma
 Common in women or kidney stone.
 Starts in childhood , going to adolescent, & adult
stage TENSION HEADACHE
 It decreases in frequency and intensity as you grow  Bilateral, constricting type of headache (parang may
old umiipit, parang may rubber band, parang may
 Kaya kapag may patient 50 yo that came to your nakahigpit na maghigpit na tali, iniipit ka), band-like
clinic claiming na super sakit ng ulo niya first time headache
evere as in don’t think na migraine yun! But pag  It happens everyday, day after day, for long periods
sinabi niya na doc opo nung dalaga ako naka- of time
experience na siya ng severe headache, tapos  Tolerable (natitiis naman daw) it does not affect
nawala then bumalik, pwede or you can still consider patient’s activities of daily living
Migraine.  Irritable lang
 Sometimes migraine disappears pag nabubuntis  No associated nausea or vomiting
maybe because of the hormones, migraine can  No aura
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 It is continuous
 Common in women, more common in middle-aged
(Why does tension headache occur? STRESS! This is
the time na maraming stress)
 Mechanism:
Contractions of the muscles
↓
HEADACHE
 Treatment: Usually due to stress non-pharma
 Pharma:
o BENZODIAZEPINES – addictive
o ANTI-DEPRESSANT – preferred

CLUSTER HEADACHE
 Rare
 Common in men
 Pain is left deep within the eye, it is very deep that it is
painful
 Typically with autonomic manifestation
o Rhinorrhea
o Conjunctiva are red
o Etc.

MED II, NEUROLOGY - JANUARY 2017, 2ND SEMESTER

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