Speciality
Spotlight

 




 


Family Practice


 

 







Neurological
Condition – Headache

  

Headache
is usually benign symptom, and only occasionally is due
to a serious underlying cause.


Even
in emergency settings, only 5 percent of patients with
headache have a serious underlying disorders.


However,
it is necessary to identify and treat these serious
conditions. Therefore it is better to classify any
patient of headache as benign or due to serious
underlying disorder.

 





Provoked
by :

 

Serious
Underlying Disorders :-


Serious Underlying Disorders :-


Red
wine         
.   


Sustained exertion

Organic odor



Hunger

Lack of sleep   

Weather changes  

Menses              

 Induced
by bending, lifting, coughing




 First
severe headache ever




 Disturbs
sleep of occurs immediately




 
upon awakening




 Abnormal
neurological examination




 
Fever or other unexplained systemic 
signs




Vomiting preceeds headache.




 Age
over 55 years.



Patients
who present with the first severe headache ever can be
due to some serious cause like meningitis, subarachnoid
hemorrhage, subdural hematoma, glaucoma or purulent
sinusitis.  In
these patients, the following laboratory tests will
reveal the underlying cause.


 


1.     
Neurological examination


2.     
Abnormal examination to be followed by MRI or CT
scan.


3.     
Measurement of blood pressure


4.     
Urine examination


5.     
Fundoscopy


6.     
Measurement of intraocular pressure.


7.     
Psychological state of the patient.

  

Migraine

Headache with nausea vomiting and photophobia. Reccurent
attack with pain free interval. Hereditary
predisposition. More common in women.

 

Aggravated by-

Red wine, menses, hunger, glare, lack of sleep,
perfumes, worry.

 

Relief by-

Sleep, NSAIDS, Sumatriptan, pregnancy.

 

Treatment-

Acute Attack-

1. Aspirin or paracetamol

2. Ibuprofen[600-800 mg.]

3. Naproxen[375-750 mg]

4. Ergotamine 3 mg

 

If oral therapy is not effective subcutaneous
sumatriptan or IV Chlopromazine or prochlorperazine.

 

Prophylaxis-

Propranolol [60-320 mg] daily

Amitriptyline [10-175 mg] daily

Valproate [500-1500 mg] daily

 

Cluster headache-

One to three short lived attacks daily of periorbital
pain over a 4 to 8 weeks followed by pain free interval
of nearly one year. Associated with nausea, nasal
stuffiness, red eye, ptosis. More common in males.
Hereditary factor is absent.

Pain is unilateral and affects the same side in
subsequent months. Attacks last for 30 minutes to 2
hours.

Precipitating factors

Food or emotional factors do not play a role. Alcohol
provokes attacks in 70% of patients.

 

Treatment-

Acute Attack

1. Inhalation of 100% oxygen [9L/min} for 15 minutes.

2. Sumatriptan 6 mg subcutaneously.

 

Prophylactic treatment:

1. Propranolol and amitriptyline not effective

2. Lithium [600-900 mg daily] is useful

3. Prednisone, 60 mg daily for 7 days followed by a
rapid tapering dose.

4. Ergotamine [1 mg] is most effective when given 1-2
hours before an expected attack.

 

Tension headache

Chronic headache with tight band like discomfort and
tight posterior neck muscles.

Pain increases slowly, fluctuates in severity and
persists for many days.

Associated with anxiety or depression.

More common in female.

 

Provoked by-

Factors similar to migraine.

 

Lumbar puncuture headache

Follows lumbar puncture within 48-72 hours. Begins when
the patient sits or stands upright and relief by
reclining or compression of abdomen. Associated with
nausea, stiff neck, photophobia, vertigo. Resolves over
a few days.

  

Treatment

1. I.V. caffeine sodium benzonate [500mg]

2. Injection of 15 ml. of autologous whole blood in
those who do not respond to caffeine.

 

Post concussion headache

Follows an apparently trivial injury to head.

Headache, dizziness, vertigo, impaired memory, anxiety,
irritability and difficulty in concentration.

Headache resolves after several weeks.

  

Treatment-

1. Symptomatic support

2. Assurance

  

Temporal [gaint cell] arteritis

Common in people above 50 years of age. It is due to
inflammation of external carotid arteries.

Headache with malaise and muscle ache. Occurs over
temporal arteries with red streaking of the overlying
skin. Pain is superficial, external to skull and not
deep inside. Scalp tenderness is marked. Burshing of
hair or resting the head over pillow is very painful. If
untreated it results into blindnness.

 

Laboratory tests

1. ESR- elevated

2. Temporal artery biopsy to confirm the diagnosis.

 

Treatment-

Prednisone 80 mg daily for 6 weeks.

  

Cough headache

Transient, severe head pain upon coughing, bending,
lifting, sneezing, stooping. Pain lasts for seconds or a
few minutes H/o lower respiratory infection with severe
coughing. More common in males.

   

Laboratory tests-

MRI is neccessary in all patients since structural
anomalies are seen in 25 percent of patient.

   

Treatment-

1. For benign disorder, indomethacin [50-200 mg] daily.

2. Threpeutic lumber puncture with removal of 40ml. of
CSF.

    

Loital headache

More common in males. Abrupt in onset and subsides in a
few minutes. If coitus is interrupted. Headache is
always benign. If it persists for hours or accompainied
by vomiting subarachnoid hemorrhage should be excluded.

    

Headache due to systemic illness

E.G SLE, infections mononucleosis chronic pulmonary
failure, inflammatory bowel disease, HIV and malignant
hypertension. Also drugs like oral contraceptives,
ovulation promoting drugs or withdrawal of
corticosteroids.

     

  • Strokes 

    Thrift AG, for the Melbourne Risk Factor Study Group (Austin and Repatriation Med Ctr, Heidelberg, Australia)

    Three Important Subgroups of Hypertensive Persons at Greater Risk of Intracerebral Hemorrhage

    Hypertension 31: 1223-1229, 1998

         

    The authors bring out that a higher risk of intracerebral hemorrhage is expected in hypertensives in the below 55 years, in smokers and those discontinuing medication for hypertension.

         

  • The SPAF III Writing Committee for the Stroke Prevention in Atrial Fibrillation Investigators (SPAF Statistical Coordinating Ctr, Seattle)

    Patients With Nonvalvular Atrial Fibrillation at Low Risk of Stroke During Treatment With Aspirin: Stroke Prevention in Atrial Fibrillation III Study

    JAMA 279: 1273-1277, 1998


        


    Events responsible for thromboembolic episodes in non valvular atrial fibrillation are 1 previous such episodes, 2 preceding congestive cardiac failure or impaired left ventricular function and females above 75 years of age and 4 systolic pressure above 160 mm Hg. Subjects without these were given 325 mg of aspirin per day and followed up for 2 years.

         

    Less than 3% of ischemic or embolic episodes including strokes were observed annually. Bleeding from aspirin occurred in 0.5% of subjects. Authors recommend aspirin instead of warfarin anticoagulation.

          

  • Lehto S, Niskanen L, Ronnemaa T, et al (Univ of Kuopio, Finland; Univ of Turku, Finland)

    Serum Uric Acid Is a Strong Predictor of Stroke in Patients With Non-Insulin-Dependent Diabetes Mellitus

    Stroke 29: 635-639, 1998

          

    High serum levels of uric acid contribute to insulin resistance and are found in non-insulin-dependent diabetes mellitus. It is an independent pointer for coronary artery disease, strokes and greater mortality in normal population. Low levels are found in patients with multiple sclerosis.

         

    The authors suggest greater research in this field.

         

  • Stroke

    Bucher HC, Griffith LE, Guyatt GH (Kantonsspital Basel, Switzerland; McMaster Univ, Hamilton, Ont, Canada)

    Effect of HMGcoA Reductase Inhibitors on Stroke: A Meta-Analysis of Randomized, Controlled Trials

    Ann Intern Med 128: 89-95, 1998


         


    This work represents MEDLINE and EMBASE search of 1996 and represents a very large data. It compares the effects of resins, fibrates and diet with 3-hydroxy-3-methylglutaryl co A reductase inhibitors in evaluation of strokes.

         

    The authors conclude that lowering of cholesterol was more with HMGcoA reductase inhibitors than others hence led to lower stroke and coronary heart disease.

         

  • RÆnning OM, Guldvog B (Central Hosp of Akershus, Nordbyhagen, Norway)


    Stroke Units Versus General Medical Wards: Twelve- and Eighteen- Month Survival: A Randomized, Controlled Trial 


    Stroke 29: 58-62, 1998

         

    Patients of a stroke were admitted either to a general medical ward or a stroke unit.

         

    Evaluation, at 12 and 18 months favoured the stroke unit. Reason for this is not known.

        




 

 

Speciality Spotlight

 

 

Neurological Condition – Headache
  

Headache is usually benign symptom, and only occasionally is due to a serious underlying cause.

Even in emergency settings, only 5 percent of patients with headache have a serious underlying disorders.

However, it is necessary to identify and treat these serious conditions. Therefore it is better to classify any patient of headache as benign or due to serious underlying disorder.
 

Provoked by :
 

Serious Underlying Disorders :-

Serious Underlying Disorders :-

Red wine         .   
Sustained exertion
Organic odor

Hunger
Lack of sleep   
Weather changes  
Menses              

 Induced by bending, lifting, coughing


 First severe headache ever


 Disturbs sleep of occurs immediately


  upon awakening


 Abnormal neurological examination


  Fever or other unexplained systemic  signs


Vomiting preceeds headache.


 Age over 55 years.

Patients who present with the first severe headache ever can be due to some serious cause like meningitis, subarachnoid hemorrhage, subdural hematoma, glaucoma or purulent sinusitis.  In these patients, the following laboratory tests will reveal the underlying cause.

 

1.      Neurological examination

2.      Abnormal examination to be followed by MRI or CT scan.

3.      Measurement of blood pressure

4.      Urine examination

5.      Fundoscopy

6.      Measurement of intraocular pressure.

7.      Psychological state of the patient.
  
Migraine
Headache with nausea vomiting and photophobia. Reccurent attack with pain free interval. Hereditary predisposition. More common in women.
 
Aggravated by-
Red wine, menses, hunger, glare, lack of sleep, perfumes, worry.
 
Relief by-
Sleep, NSAIDS, Sumatriptan, pregnancy.
 
Treatment-
Acute Attack-
1. Aspirin or paracetamol
2. Ibuprofen[600-800 mg.]
3. Naproxen[375-750 mg]
4. Ergotamine 3 mg
 
If oral therapy is not effective subcutaneous sumatriptan or IV Chlopromazine or prochlorperazine.
 
Prophylaxis-
Propranolol [60-320 mg] daily
Amitriptyline [10-175 mg] daily
Valproate [500-1500 mg] daily
 
Cluster headache-
One to three short lived attacks daily of periorbital pain over a 4 to 8 weeks followed by pain free interval of nearly one year. Associated with nausea, nasal stuffiness, red eye, ptosis. More common in males. Hereditary factor is absent.
Pain is unilateral and affects the same side in subsequent months. Attacks last for 30 minutes to 2 hours.
Precipitating factors
Food or emotional factors do not play a role. Alcohol provokes attacks in 70% of patients.
 
Treatment-
Acute Attack
1. Inhalation of 100% oxygen [9L/min} for 15 minutes.
2. Sumatriptan 6 mg subcutaneously.
 
Prophylactic treatment:
1. Propranolol and amitriptyline not effective
2. Lithium [600-900 mg daily] is useful
3. Prednisone, 60 mg daily for 7 days followed by a rapid tapering dose.
4. Ergotamine [1 mg] is most effective when given 1-2 hours before an expected attack.
 
Tension headache
Chronic headache with tight band like discomfort and tight posterior neck muscles.
Pain increases slowly, fluctuates in severity and persists for many days.
Associated with anxiety or depression.
More common in female.
 
Provoked by-
Factors similar to migraine.
 
Lumbar puncuture headache
Follows lumbar puncture within 48-72 hours. Begins when the patient sits or stands upright and relief by reclining or compression of abdomen. Associated with nausea, stiff neck, photophobia, vertigo. Resolves over a few days.
  
Treatment
1. I.V. caffeine sodium benzonate [500mg]
2. Injection of 15 ml. of autologous whole blood in those who do not respond to caffeine.
 
Post concussion headache
Follows an apparently trivial injury to head.
Headache, dizziness, vertigo, impaired memory, anxiety, irritability and difficulty in concentration.
Headache resolves after several weeks.
  
Treatment-
1. Symptomatic support
2. Assurance
  
Temporal [gaint cell] arteritis
Common in people above 50 years of age. It is due to inflammation of external carotid arteries.
Headache with malaise and muscle ache. Occurs over temporal arteries with red streaking of the overlying skin. Pain is superficial, external to skull and not deep inside. Scalp tenderness is marked. Burshing of hair or resting the head over pillow is very painful. If untreated it results into blindnness.
 
Laboratory tests
1. ESR- elevated
2. Temporal artery biopsy to confirm the diagnosis.
 
Treatment-
Prednisone 80 mg daily for 6 weeks.
  
Cough headache
Transient, severe head pain upon coughing, bending, lifting, sneezing, stooping. Pain lasts for seconds or a few minutes H/o lower respiratory infection with severe coughing. More common in males.
   
Laboratory tests-
MRI is neccessary in all patients since structural anomalies are seen in 25 percent of patient.
   
Treatment-
1. For benign disorder, indomethacin [50-200 mg] daily.
2. Threpeutic lumber puncture with removal of 40ml. of CSF.
    
Loital headache
More common in males. Abrupt in onset and subsides in a few minutes. If coitus is interrupted. Headache is always benign. If it persists for hours or accompainied by vomiting subarachnoid hemorrhage should be excluded.
    
Headache due to systemic illness
E.G SLE, infections mononucleosis chronic pulmonary failure, inflammatory bowel disease, HIV and malignant hypertension. Also drugs like oral contraceptives, ovulation promoting drugs or withdrawal of corticosteroids.
     

  • Strokes 
    Thrift AG, for the Melbourne Risk Factor Study Group (Austin and Repatriation Med Ctr, Heidelberg, Australia)
    Three Important Subgroups of Hypertensive Persons at Greater Risk of Intracerebral Hemorrhage
    Hypertension 31: 1223-1229, 1998
         
    The authors bring out that a higher risk of intracerebral hemorrhage is expected in hypertensives in the below 55 years, in smokers and those discontinuing medication for hypertension.
         

  • The SPAF III Writing Committee for the Stroke Prevention in Atrial Fibrillation Investigators (SPAF Statistical Coordinating Ctr, Seattle)
    Patients With Nonvalvular Atrial Fibrillation at Low Risk of Stroke During Treatment With Aspirin: Stroke Prevention in Atrial Fibrillation III Study
    JAMA 279: 1273-1277, 1998
        
    Events responsible for thromboembolic episodes in non valvular atrial fibrillation are 1 previous such episodes, 2 preceding congestive cardiac failure or impaired left ventricular function and females above 75 years of age and 4 systolic pressure above 160 mm Hg. Subjects without these were given 325 mg of aspirin per day and followed up for 2 years.
         
    Less than 3% of ischemic or embolic episodes including strokes were observed annually. Bleeding from aspirin occurred in 0.5% of subjects. Authors recommend aspirin instead of warfarin anticoagulation.
          

  • Lehto S, Niskanen L, Ronnemaa T, et al (Univ of Kuopio, Finland; Univ of Turku, Finland)
    Serum Uric Acid Is a Strong Predictor of Stroke in Patients With Non-Insulin-Dependent Diabetes Mellitus
    Stroke 29: 635-639, 1998
          
    High serum levels of uric acid contribute to insulin resistance and are found in non-insulin-dependent diabetes mellitus. It is an independent pointer for coronary artery disease, strokes and greater mortality in normal population. Low levels are found in patients with multiple sclerosis.
         
    The authors suggest greater research in this field.
         

  • Stroke
    Bucher HC, Griffith LE, Guyatt GH (Kantonsspital Basel, Switzerland; McMaster Univ, Hamilton, Ont, Canada)
    Effect of HMGcoA Reductase Inhibitors on Stroke: A Meta-Analysis of Randomized, Controlled Trials
    Ann Intern Med 128: 89-95, 1998
         
    This work represents MEDLINE and EMBASE search of 1996 and represents a very large data. It compares the effects of resins, fibrates and diet with 3-hydroxy-3-methylglutaryl co A reductase inhibitors in evaluation of strokes.
         
    The authors conclude that lowering of cholesterol was more with HMGcoA reductase inhibitors than others hence led to lower stroke and coronary heart disease.
         

  • RÆnning OM, Guldvog B (Central Hosp of Akershus, Nordbyhagen, Norway)
    Stroke Units Versus General Medical Wards: Twelve- and Eighteen- Month Survival: A Randomized, Controlled Trial 
    Stroke 29: 58-62, 1998
         
    Patients of a stroke were admitted either to a general medical ward or a stroke unit.
         
    Evaluation, at 12 and 18 months favoured the stroke unit. Reason for this is not known.
        

 

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