Headache cephalalgia

1
Headache (cephalalgia)

• Any ache or pain in head caused by stimulation of
  pain-sensitive structures in cranium or
  extracranial tissues in head neck
• Incidence 43.2 per 1000 outpatient visits per year

2
Pathophysiology of Headaches

• Intracranial structures sensitive to pain
• Trigeminal, facial, glossopharyngeal vagus
  nerve, first three cervical nerves
• Cranial blood vessels
• Venous sinuses
• Dura at base of brain.

3
Pathophysiology of Headaches

• Extra-cranial causes of pain
• Dilation or distortion of extracranial vessels
  Muscle tension
• Sinusitis
• Dental abscess, Mastoiditis
• Eye ear diseases

4
Types of Headaches

• Vascular Headache
• Migraine headaches
• Cluster headaches
• Tension Headache
• Muscle contraction headaches
• Traumatic headaches
• Traction-Inflammatory Headache
• Traction headaches
• Temporal arteritis

5
Migraine Headache

• Episodic vascular disorder
• Begins in childhood
• Found in 5 of population, usually more in
  females
• Frequently is familial

6
Signs Symptoms of Migraine Headache

• Paroxysmal, throbbing, unilateral head pain,
  often in temporal area
• Nausea, vomiting
• Aura type has 4 stages
• Prodrome
• Aura phase
• Headache phase
• Recovery phase

7
Prevention of Migraines

• Beta Ca-channel blockers
• Serotonin-blocker (methysergide)
• Anticonvulsants
• Tricyclic antidepressants

8
Prevention of Migraines

• Avoid dietary agents such as tyramine, nitrate,
  glutamatetry to eliminate vinegar, chocolate,
  pork, onions, sour cream, alcohol, excessive
  caffeine, citrus fruits, bananas, yogurt, figs,
  cheese, cured sandwich meats, chicken livers,
  fermented or marinated foods, avocados, MSG.

9
Management of Migraines

• Serotonin receptor agonists
• Ergotamine
• Sumatriptan
• Dihydroergotamine (DHE)
• Lidocaine nose drops

10
Management of Migraines

• Other analgesics
• Lie quietly in darkened room
• Elevate HOB 30 degrees

11
Acute Spinal Cord Injury

• From impact accident that produces concussion,
  contusion, laceration, or hemorrhage within
  vertebral column.
• Approximately 14,000 to 20,000 such cases per
  year result in permanent paraplegia or
  quadriplegia.
• 85 males, age 16-30

12
Incidence Etiology of Spinal Cord Injury

• Factors--95 are flexion injuries
• automobile collisions/motorcycles 50
• diving accidents 10
• falls 8
• impact blunt objects
• gunshot other penetrating wounds
• athletics
• seat belts

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Acute Spinal Cord Injury

• Class A Complete
• absence of all voluntary motor, sensory,
  vasomotor function
• below level of injury

14
Acute Spinal Cord Injury

• Class B Incomplete with preserved sensation only
• no motor function below level of injury
• Class C Incomplete with nonuseful motor function

15
Acute Spinal Cord Injury

• Class D Incomplete with useful motor function
• Class E--Complete Recovery

16
Spinal Cord Functional Areas

• Anterior Horn--motor (efferent)
• Posterior Horn--sensory (afferent)
• Lateral Dorsal Spinothalamic tracts--pain,
  temp, proprioception

17
Spinal Shock

• Complete neurovascular shutdown--
• All reflex activity below level of injury lost
  or absent
• See flaccid paralysis, absence of deep tendon
  reflexes, absence of cutaneous sensation, urinary
  fecal retention, unstable BP with loss of
  sympathetic response

18
Manifestations by Level of Cord Injury

• C4 higher loss of all skeletal muscle
  function, respiratory
• C4-5 some loss of all skeletal muscle function,
  including intercostal muscles. Phrenic nerve
  intact
• C6-8 Quadriplegia with increased resp.
  function. Some movement neck, shoulders, chest,
  upper arms. Independent breathing.

19
Manifestations by Level of Cord Injury

• T1-3 neck, shoulder, chest arm, hand, resp.
  function. Can sit.
• T4-10 more stable trunk muscles. Paraplegia.
• T11-12 Use of upper extremities, neck,
  shoulders good. Loss of voluntary bowel
  bladder function.

20
Manifestations by Level of Cord Injury

• L3-S1 Functional upper body muscles most in
  lower extremities. Loss of bowel bladder
  function. Diminished penile erection.
• S2-4 Muscle groups function with some weakness
  in legs. Bowel bladder flaccidity--retention
  problems. Possible male impotence.

21
Management of Spinal Cord Injury

• Stabilize injury site--keep spine in alignment,
  skeletal traction
• Respiratory support (cervical injury) with
  nasotracheal intubation
• Maintain cord perfusion--mean arterial BP 80-90
  mm Hg.

22
Management of Spinal Cord Injury

• Corticosteroids NSAIDs to lessen inflammation
• H2 blockers Antacids

23
Management of Spinal Cord Injury

• Nasogastric tube--prevent aspiration
• Decompression laminectomy--spinal fusion,
  Harrington rods
• Muscle relaxants, analgesics
• Urinary catheterization
• Bowel incontinence
• Treat autonomic dysreflexia

24
Back Pain

• Most frequent cause of disability for those yrs.
• Usually involves cervical or lumbosacral
  vertebrae
• Cost to society--up to 50 billion annually.

25
Cervical Back Pain

• Usually from herniation of nucleus pulposus.
  Spinal nerve root is compressed.
• Can be from degenerative joint disease--osteophyte
  compresses nerve
• Can be from muscle strain or ligament sprain

26
Lumbosacral Back Pain

• Causes of low back pain
• Muscle strain or spasm
• Ligament sprain
• Disk injury
• Herniation of nucleus pulposus--see severe,
  burning, stabbing pain down leg or foot

27
Etiology of Herniated Disc

• Hyperflexion or twisting of back
• Trauma
• Repetitive minor stresses-lifting

28
Etiology of Herniated Disc

• Factors
• Obesity
• Age-degenerative joint disease
• Poor posture
• Wearing high heels
• Congenital spinal conditions
• Scoliosis

29
Signs/Symptoms of Herniated Disc

• stabbing, continuous pain in area near affected
  disc
• pain radiates down arm (cervical) or down
  posterior leg (lumbosacral)
• lack of sensation, numbness
• decreased arm or foot strength

30
Diagnostic Procedures for Herniated Disc

• Flat plate--anterior, posterior, lateral
• CT scan
• MRI
• Myelogram, electromyography, nerve conduction
  studies, somatosensory evoked potentials, motor
  evoked potentials

31
Cervical Herniation Management

• Immobilization
• C-collar, traction
• Pain relief
• Physical Therapy

32
Cervical Herniation Management

• Surgery
• cervical discectomy
• laminectomy
• spinal fusion
• spinal implant

33
Post-op Management of Cervical Discectomy

• Neuro assessment VS
• q 4 hrs.
• Position flat 12-24 hrs., logroll
• Pain control
• Pulm. care
• Inspect surgical site--hemorrhage, pressure,
  leakage

34
Thoracic Herniation Management

• Rest
• Pain control
• Physical therapy
• Surgery
• transthoracic approach
• lateral extracavity approach

35
Post-operative Management of Thoracic Discectomy

• Neuro VS assessment q 4 hrs.
• Pulm care
• Check operative site
• Pain control

36
Lumbar Herniation Management

• Bed rest on firm mattress
• Proper movement
• Medications NSAIDs, corticosteroids, muscle
  relaxants
• Moist heat massage

37
Lumbar Herniation Management

• Surgery
• microdiscectomy
• percutaneous discectomy
• microLaser discectomy

38
Post-operative Management Lumbar Discectomy

• Neuro assessment, VS q 4 prn
• Inspect incisional sites
• Assess urinary retention
• Position with slight knee flexion, logroll
• Control pain
• Pulmonary care