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1. Dr Ranjan Pain Management for Headache Dr Ranjan Pain Management for Headache Ranjan Kumar Pain Clinic, Persahabatan Hospital Jakarta Headaches • Headache is one among the most common reasons patients seek medical attention. • The gold standard for diagnosis and management of headache is a careful interview supported by neurological and general medical examinations (De Luca and Bartleson, 2010).(International Headache Society Classification Subcommittee, 2004). Common causes of headache Primary headache Secondary headache • Tension –type 69% • Systemic infection 63% • Migraine 16% • Head injury 4% • Idiopathic • Vascular disorders 1% • Stabbing 2% • Subarachnoid hemorrhage • Exertional 1% < 1% • Cluster 0,1% • Brain tumor 0,1% Evaluation of headache. Bhavna Rote.Clinical methods in Pain Medicine. 2nd edition.Gautam Das, 2017. hal :23-37 Various structures, which can be the pain generators or source of pain for headache. Evaluation of headache. Bhavna Rote.Clinical methods in Pain Medicine. 2nd edition.Gautam Das, 2017. hal :23-37 Classification of headaches Primary Secondary Painful cranial (those not associated (those attributed to an neuropathies, other facial with an underlying underlying pathologic pains n other headaches pathology) condition) Migraine infectious Tension Type neoplastic Vascular, drug Cluster induced, headaches idiopathic. • By 1988, recognizing the need for improvement in headache classification, the International Headache Society (IHS) published a new system, the second edition of the International Headache Classification (ICHD-2) • Recently International Headache Society had published ICHD, 3rd edition (beta version) Primary headache Episodic attacks of head pain Chronic neurologic disorder And associated symptoms Migraine headache Women 18% Prevalence in US Men 6% Never seek medical Estimated to be advices approximately 50% Treat themselves Diagnostic criteria for 1.1 migrain without aura Diagnostic criteria for 1.2 migrain with aura Headache. A pocket guide of pain management. Copyright 2010. Inflexxion.Hal 65-77 Tension-type headache Studies shown Prevalence of -25% of TTH Most episodic type have migraine common type vary widely -62% of (30-80%) migraineurs have TTH Diagnostic criteria for tension-type headache (TTH) The headache classification (modified) ICHD- 3 code Headache. A pocket guide of pain management. Copyright 2010. Inflexxion.Hal 65-77 Cluster headache Third major type of More frequent in men primary headache than women ( 5x ) Occuring in a series Usually occuring once Strictly unilateral Lasting for 15-180 which last from or few times a day at headache minutes several weeks to characteristic time several months Diagnostic criteria for cluster headache The picture can't be displayed. Autonomic characteristics of cluster headache The picture can't be displayed. The picture can't be displayed. Diagnostic criteria for Episodic and Chronic cluster headache The picture can't be displayed. The picture can't be displayed. The picture can't be displayed. (IHS criteria) Secondary Headache • attributed to an underlying pathologic condition : ---Head and/or neck trauma. ---Cranial or cervical vascular disorder ---Cranial nonvascular disorder ---Infection. ---Disorder of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cranial structure . ---Psychiatric disorder Painful cranial neuropathies and other facial pains • Trigeminal neuralgia • Glossopharyngeal neuralgia • Nervus intermedius (facial nerve) neuralgia • Occipital neuralgia • Optic neuritis • Headache attributed to ischemic ocular motor nerve palsy • Tolosa hunt syndrome • Paratrigeminal oculosympathetic (Raeder’s) syndrome. • Recurrent painful opthalmoplegic neuropathy. • Burning mouth syndrome (BMS). • Persistent Idiopathic facial pain (PIFP) • Central neuropathic pain The picture can't be displayed. Trigeminal neuralgia. Clinical diagnostic criteria The picture can't be displayed. The picture can't be displayed. Glossopharyngeal neuralgia Unilateral severe pain Felt in the distribution of the glossopharyngeal nerve, auricular n pharyngeal branches of the vagus nerve. Occurs in the ear, posterior third of the tongue n tonsillar fossa. Rare, 1/100 as common TN. Most frequently in middle aged men n women. Majority idiopathic or related to neurovascular compression of cranial nerves. Tx, carbamazepine/gabapentin, intervention or surgical. The picture can't be displayed. Occipital neuralgia Characterized by sharp pain originating in the back of the head. Pain radiating into the distribution pof GON n LON n sometimes into the eye. Most cases are unilateral. Causes : idiopathic, trauma/compression to involved nerves. Tx : antiepileptic agents (1st line), intervention or surgical. The picture can't be displayed. The picture can't be displayed. The picture can't be displayed. Diagnosis is the most important part in any branch of clinical practice for management of patient’s complains. To reach the diagnosis 1. Proper history 2. Clinical examination 3. Investigations special subheading under investigation part, called diagnostic interventions or diagnostic nerve blocks which help us in finding pain generators. Patient’S history Headache •Age of onset,location,pain intensity,progression, character, duration,frequency,aggravating n relieving factors, associated history features, aura symptoms, impact of daily activity. Family history •Familial hemiplegic migraine •Secondary headaches Past history of •Investigations •Medications headache •Any changes of character or pattern. Medicinal Some medicines itself can cause headache: oral contraseptives, hormone replacement therapy, history antihistamin,nitrate, etc. Medication overuse., History of Cancer, head trauma, asthma,high Blood Comorbidities pressure,depression, Insomnia,Infection of dental, nose, ears. Physical Examination -body habitus -blood pressure • General examination -fever • Systemic examination : -skin changes Memory, --CNSàhigher function Concentration, Speech, àInspection Orientation àpalpation of head, face and neck àpercussion àauscultation àcranial nerve examination (N I-N XII) Investigation The picture can't be displayed. The picture can't be displayed. The picture can't be displayed. References • 1. Evaluation of headache. Bhavna Rote.Clinical methods in Pain Medicine. 2nd edition.Gautam Das, 2017. hal :23-37 • 2.Painful Disease States: Headaches. Brinder Vij and Stewart J.Tepper. Fundamentals of Pain medicine. Springer International Publishing AG 2018. hal 281-290 • 3.Specific Clinical Situations. Acute Pain Management: Scientific Evidence. Australian and New Zealand College of Anesthetics and Pain Medicine. 4th edition.Acute Pain Management: Scientific Evidence.2015. hal 317-327. • 4.Evaluation of headache. Zachary McCormick and Rajiv Reddy. Treatment of chronic pain conditions. Springer science and Bussiness media LLC 2017. Hal 25-28 • 5.Pain Management Secrets. 4th edition. Elsevier 2018. • 6.Headache. A pocket guide of pain management. Copyright 2010. Inflexxion.Hal 65-77.
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