details of primary and secondary headache and the approach

1. Disclosure of Conflict of Interest
I Dr. AHMAD SALADDIN SULTAN
DO NOT have a financial interest/arrangement or affiliation
with anyone in relation to this
program/presentation/organization that could be perceived as
a real or apparent conflict of interest in the context of the
subject of this presentation.

2. Neurological Emergencies
Dr.Ahmad Saladdin Sultan
Specialist Emergency Medicine
M.B.Ch.B, M.R.C.E.M, F.J.M.C.H.S(A&E)

3. PART ONE
HEADACHE

4. Headache is pain in any region of the head.
Headaches may occur on one or both sides of the head,
be isolated to a certain location, radiate across the head
from one point.

5. • As many as 90 percent of all benign headaches fall under a few categories,
including migraine, tension-type, cluster, and chronic daily headache.
While episodic tension-type headache is the most frequent headache type
in population-based studies, migraine is the most common diagnosis in
patients presenting to primary care physicians with headache. The one-
year prevalence of episodic tension-type headache (TTH) is approximately
65 percent, but most people with tension-type headache do not present
to physicians for care.
• Cluster headache typically leads to significant disability and most of these
patients will come to medical attention. However, cluster headache
remains an uncommon diagnosis in primary care settings because of
overall low prevalence in the general population (<1 percent).

6. • Primary Headache : of unknown cause
Symptom Migraine Tension-type Cluster
Location
Adults: Unilateral in 60 to
70 percent, bifrontal or
global in 30 percent
Children and adolescents:
Bilateral in majority
Bilateral
Always unilateral, usually
begins around the eye or
temple
Characteristics
Gradual in onset,
crescendo pattern;
pulsating; moderate or
severe intensity;
aggravated by routine
physical activity
Pressure or tightness
which waxes and wanes
Pain begins quickly,
reaches a crescendo
within minutes; pain is
deep, continuous and
explosive in quality
Patient appearance
Patient prefers to rest in
a dark, quiet room
Patient may remain
active or may need to
rest
Patient remains active

7. Secondary Headache : there is a cause

8. History: The gold standard for diagnosis and management of headache.
A thorough history can focus the physical examination and determine the need for further
investigations and neuroimaging studies. A systematic history should include the following:
●Age at onset
●Presence or absence of aura and prodrome
●Frequency, intensity, and duration of attack
●Number of headache days per month
●Time and mode of onset
●Quality, site, and radiation of pain
●Associated symptoms and abnormalities
●Family history of migraine
●Precipitating and relieving factors
●Effect of activity on pain
●Relationship with food/alcohol
●Response to any previous treatment
●Any recent change in vision
●Association with recent trauma

9. The examination of an adult with headache complaints should cover the following
areas:
• Obtain blood pressure and pulse
• Listen for bruit at neck, eyes, and head for clinical signs of arteriovenous
malformation
• Palpate the head, neck, and shoulder regions
• Check temporal and neck arteries
• Examine the spine and neck muscles
The neurologic examination should cover mental status testing, cranial nerve
examination, funduscopy and otoscopy, and symmetry on motor, reflex, cerebellar
(coordination), and sensory tests.

10. MIGRAINE:
A. At least 5 attacks fulfilling criteria B–D
B. Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)
C. Headache has at least 2 of the following characteristics:
• 1. unilateral location
• 2. pulsating quality
• 3. moderate or severe pain intensity
• 4. aggravation by or causing avoidance of routine
physical activity (eg, walking or climbing stairs)
D. During headache at least 1 of the following:
• 1. nausea and/or vomiting
• 2. photophobia and phonophobia
• E. Not attributed to another disorder
The International Classification of Headache Disorders (ICHD)

11. TENSION HEADACHE:
A. At least 10 episodes occurring on <1 day/month on average (<12 days/year) and
fulfilling criteria B–D
B. Headache lasting from 30 minutes to 7 days
C. Headache has at least 2 of the following characteristics:
• 1. bilateral location
• 2. pressing/tightening (non-pulsating) quality
• 3. mild or moderate intensity
• 4. not aggravated by routine physical activity such as walking or climbing stairs
D. Both of the following:
• 1. no nausea or vomiting (anorexia may occur)
• 2. no more than one of photophobia or phonophobia
• E. Not attributed to another disorder
The International Classification of Headache Disorders (ICHD)

12. CLUSTER HEADACHE:
A. At least 5 attacks fulfilling criteria B–D
B. Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting
15-180 minutes if untreated
C. Headache is accompanied by at least 1 of the following:
• 1. ipsilateral conjunctival injection and/or lacrimation
• 2. ipsilateral nasal congestion and/or rhinorrhoea
• 3. ipsilateral eyelid oedema
• 4. ipsilateral forehead and facial sweating
• 5. ipsilateral miosis and/or ptosis
• 6. a sense of restlessness or agitation
D. Attacks have a frequency from 1 every other day to 8/day
E. Not attributed to another disorder
The International Classification of Headache Disorders (ICHD)

13. Paying attention to danger signs is important since headaches may be the presenting
symptom of a space-occupying mass or vascular lesion, infection, metabolic disturbance, or a
systemic problem. The following features in the history can serve as warning signs of possible
serious underlying disease.
The mnemonic SNOOP is a reminder of the danger signs ("red flags") for the presence of serious
underlying disorders that can cause acute or sub-acute headache :
●Systemic symptoms, illness, or condition (eg, fever, weight loss, cancer, pregnancy,
immunocompromised state including HIV).
●Neurologic symptoms or abnormal signs (eg, confusion, impaired alertness or consciousness,
papilledema, focal neurologic symptoms or signs, meningismus, or seizures).
●Onset is new (particularly for age >40 years) or sudden (eg, "thunderclap").
●Other associated conditions or features (eg, head trauma, illicit drug use, or toxic exposure;
headache. awakens from sleep, is worse with Valsalva maneuvers, or is precipitated by cough,
exertion, or sexual activity).
●Previous headache history with headache progression or change in attack frequency, severity,
or clinical features.

15. TENSION HEADACHE
• The usual abortive treatment can be any simple analgesic (aspirin, NSAIDs, acetaminophen).
The most effective prophylactic drug is amitriptyline in the dosage of 50–150 mg per day.
Lower dosage may be tried initially.
MIGRAINE HEADACHE
• There are certain specific treatments for migraines, which are given as follows:
• • Analgesics: Aspirin, acetaminophen
• • NSAIDs: Naproxen, ibuprofen
• • 5-HT1 agonists-oral: Ergotamine, rizatriptan, naratriptan, zolmitriptan
• • 5-HT1 agonists-nasal: Dihydroergotamine, sumatriptan, zolmitriptan
• • 5-HT1 agonists-parenteral: Dihydroergotamine, sumatriptan
• • Dopamine antagonists: Metoclopramide, prochlorperazine.

16. CLUSTER HEADACHE
• Nasal oxygen (8–10 L/min), sumatriptan (subcutaneous 6 mg) and dihydroergotamine
(subcutaneous or intramuscular).
• The maintenance prophylactic agents include calcium channel blockers (verapamil 80 mg
three times a day to a maximum dose of 720 mg per day; monitor with ECG if total daily
dose is more than 480 mg/ day), methylsergide, lithium (300 mg three times daily; monitor
with lithium levels), topiramate (100–400 mg/day), gabapentine (1,200–3,600 mg/day),
melatonin (9–12 mg/day).

17. PART TWO
Bell’s Palsy

18. Acute peripheral CN VII (facial nerve) palsy of unknown cause.
However, the terms "Bell's palsy" and "idiopathic facial paralysis" may no
longer be considered. A peripheral facial palsy is a clinical syndrome of
many causes.

19. Sir Charles Bell, Scottish Surgeon First described in early 1800s based on
trauma to facial nerves.

21. Bell's palsy, defined as an acute peripheral facial nerve palsy of
unknown cause, represents about half of all cases of facial nerve
palsy . The annual incidence rate is between 13 and 34 cases per
100,000 population . There is no race, geographic, or gender
predilection, but the risk is three times greater during pregnancy,
especially in the third trimester or in the first postpartum week.
Diabetes is present in about 5 to 10 percent of patients.

22. -Herpes simplex Virus now is widely accepted as most common cause.
-Herpes zoster is probably the second most common viral infection associated
with facial palsy.
-An inactivated intranasal influenza vaccine.
-Genetic predisposition in some cases.
-Diabetes is a risk factor for microangiopathy.
-The increased risk of Bell’s palsy associated with pregnancy, which is most
marked in the third trimester and the first postpartum week, may be caused
by pregnancy-related fluid retention leading to compression of the nerve or
perineural edema.

23. -Patients with Bell's palsy typically present with the sudden onset (usually over hours) of
unilateral facial paralysis.
-Common findings include the eyebrow sagging, inability to close the eye, disappearance of the
nasolabial fold, and drooping at the affected corner of the mouth, which is drawn to the
unaffected side.
-Decreased tearing, hyperacusis, and/or loss of taste sensation on the anterior two-thirds of the
tongue may help to site the lesion in the fallopian canal, but these findings are of little practical
use other than as indicators of severity.
-patients had bilateral facial palsy, possibly from the same pathogenesis as typical unilateral Bell's
palsy.
Examination : Facial movement is assessed by observing the response to command for closing
the eyes, elevating the brow, frowning, showing the teeth, puckering the lips, and tensing the soft
tissues of the neck to observe for platysma activation. The evaluation also includes a general
physical examination and neurologic examination. Particular attention is directed at the external
ear to look for vesicles or scabbing (which indicates zoster) and for mass lesions within the
parotid gland.

24. Thus, dissociation of movement of the face to command from
spontaneous movement, as in smiling, indicates an upper motor neuron
lesion. Lack of dissociation (absence of both voluntary and spontaneous
movement) indicates a lower motor neuron (peripheral) lesion.

25. -Herpes zoster (Ramsey Hunt syndrome).
-Otitis media.
-Lyme disease: could be Bilateral.
-Guillain-Barré syndrome: could be bilateral.
-HIV infection: could be bilateral.
-Sarcoidosis: could be bilateral.
-Tumor.
-Trauma.
-Stroke.

26. • oral glucocorticoids for all patients with idiopathic facial nerve palsy (Bell's
palsy) or facial nerve palsy of suspected viral etiology, consistent with
current guidelines. Treatment should preferably begin within three days of
symptom onset. Our suggested regimen is prednisone (60 to
80 mg/day) for one week.
• The suspicion that Bell's palsy is caused by herpes simplex virus in most
patients led to trials of antiviral therapy.
• Suggested early combined therapy with prednisone (60 to 80 mg per day)
plus valacyclovir (1000 mg three times daily) for one week for patients
with severe facial palsy at presentation.
• Eye care In severe cases of Bell's palsy, the cornea may be at risk because
of poor eye lid closure and reduced tearing.

27. • The prognosis of Bell's palsy is related to the severity of the lesion. A
simple rule is that clinically incomplete lesions tend to recover.
• The prognosis is favorable if some recovery is seen within the first 21 days
of onset. A diagnosis of Bell's palsy is doubtful if some facial function,
however small, has not returned within three to four months.

28. PART THREE
SEIZURE

29. Seizures are a common occurrence, affecting an estimated 8 to 10
percent of the population over a lifetime.
Seizures account for 1 to 2 percent of all emergency department
visits, and approximately one-quarter of these will be a first seizure

30. A seizure is a sudden change in behavior caused by electrical
hypersynchronization of neuronal networks in the cerebral cortex.
• Acute symptomatic seizure — Refers to a seizure that occurs at the time
of a systemic insult or in close temporal association with a documented
brain insult . Such insults include metabolic derangements, drug or alcohol
withdrawal, and acute neurologic disorders such as stroke, encephalitis, or
acute head injury.
• Unprovoked seizure — Refers to a seizure of unknown etiology as well as
one that occurs in relation to a preexisting brain lesion or progressive
nervous system disorder. Unprovoked seizures that are determined to be
due to an underlying brain lesion or disorder are also referred to as
remote symptomatic seizures. They carry a higher risk of future epilepsy
compared with acute symptomatic seizures.

31. -Focal seizures with retained awareness — The symptoms of focal seizures
with retained awareness (previously called simple partial seizures) vary from
one patient to another and depend entirely on the part of the cortex that is
disrupted at the onset of the seizure.
-Focal seizures with impaired awareness — Some focal seizures are
associated with altered awareness at the onset of the seizure or as it
progresses. These seizures, previously called complex partial seizures, are the
most common type of seizure in adults with epilepsy.
-Generalized seizures — Generalized tonic-clonic seizures (also called grand
mal seizures, major motor seizures, or convulsions) are the most common
type of generalized seizures.

32. Seizure is primarily a clinical diagnosis, and accurate diagnosis requires
differentiating seizure from other common clinical events that can mimic
seizure.
In adults, the primary conditions to consider in patients presenting with
transient or paroxysmal neurologic events are
●Syncope
●Transient ischemic attack (particularly in older adults)
●Migraine
●Panic attack and anxiety
●Psychogenic nonepileptic seizure
●Paroxysmal movement disorders

33. Medical history
Description of the event
Postictal period
Seizure precipitants or triggers
Prior events
Medications and substances
Past medical history
Family history
Physical and neurologic examination
Laboratories
Electrocardiogram
ADDITIONAL TESTING

34. Early postseizure management — Most seizures remit spontaneously within two
minutes and rapid administration of a benzodiazepine or antiseizure drug is not
required. Nonetheless, intravenous access is typically secured by paramedics or in
the emergency department setting for patients presenting acutely so that
parenteral medications can be administered if the seizure is more prolonged or
recurs.
When to start antiseizure drug therapy — The decision whether to start
antiseizure drug therapy immediately after a first seizure depends on multiple
factors, including the probability that the event represented a seizure, the
suspected or confirmed cause of the seizure based on the initial evaluation, the
stability of the patient, and the estimated risk of recurrent seizure.
Indications for hospitalization — Hospitalization may be required for patients
who have a first seizure associated with a prolonged postictal state, incomplete
recovery, or serious seizure-related injury. Other indications for hospitalization
include status epilepticus, the presence of a neurologic or systemic illness or insult
requiring additional evaluation and treatment, or questions regarding compliance.

36. Questions?