Secondary Headaches Trauma, Neoplasm, and LP

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Secondary Headaches Trauma, Neoplasm, and LP

• E.FAKHARIAN, M.D.
• Associate Professor of Neurosurgery
• Kashan University of Medical Sciences
• Kashan-Iran
• 11.8.1388
• fakharian-e_at_kaums.ac.ir
• efakharian_at_gmail.com

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Reference/s

• The Headache Cooperative of New England
  Comprehensive Review of Headache Medicine
• MORRIS LEVIN
• Oxford University Press
• 2008

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Secondary HeadachesTrauma

• Head trauma, neck trauma, and whiplash
  injuries are all recognized causes of acute and
  chronic headache presentations
• The typical headache after trauma is similar to
  tension-type, migraine and even cluster headache.

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Secondary HeadachesTrauma

• The IHS recognizes headaches as
  post-traumatic only when they begin within 1
  week after the trauma. We believe that the
  official criteria should be changed to between 1
  and 3 months after trauma.
• Women have a greater chance of
  developing post-traumatic headache. Older
  individuals tend to have more permanent headaches
  after trauma than younger ones or children.
  Children usually experience very brief headaches
  after trauma and are headache-free in 24 to 48
  hours.

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Diagnostic Criteria for Acute Post-traumatic
Headache Attributed to Mild Head Injury

• Headache, no typical characteristics known,
  fulfilling criteria C and D
• B. Head trauma with all the following
• 1. Either no loss of consciousness, or loss of
  consciousness of lt30 minutes duration
• 2. Glasgow Coma Scale (GCS) gt13
• 3. Symptoms and/or signs diagnostic of concussion
• C. Headache develops within 7 days after head
  trauma
• D. One or other of the following
• 1. Headache resolves within 3 months after head
  trauma
• 2. Headache persists but 3 months have not yet
  passed since head trauma

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Diagnostic Criteria for Acute Post-traumatic
Headache Attributed to Moderate or Severe Head
Injury

• A. Headache, no typical characteristics known,
  fulfilling criteria C and D
• B. Head trauma with at least one of the
  following
• 1. Loss of consciousness for gt30 minutes
• 2. Glasgow Coma Scale (GCS) lt13
• 3. Post-traumatic amnesia for gt48 hours
• 4. Imaging demonstration of a traumatic brain
  lesion (cerebral hematoma, intracerebral and/or
  subarachnoid hemorrhage, brain contusion and/or
  skull fracture)
• C. Headache develops within 7 days after head
  trauma or after regaining consciousness following
  head trauma
• D. One or other of the following
• 1. Headache resolves within 3 months after head
  trauma
• 2. Headache persists but 3 months have not yet
  passed since head trauma

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Diagnostic Criteria for Chronic Post-traumatic
Headache Attributed to Mild Head Injury

• A. Headache, no typical characteristics known,
  fulfilling criteria C and D
• B. Head trauma with all the following
• 1. Either no loss of consciousness, or loss of
  consciousness of lt30 minutes duration
• 2. Glasgow Coma Scale (GCS) gt13
• 3. Symptoms and/or signs diagnostic of concussion
• C. Headache develops within 7 days after head
  trauma
• D. Headache persists for gt3 months after head
  trauma

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Diagnostic criteria for Chronic Post-traumatic
Headache Attributed to Moderate or Severe Head
Injury

• A. Headache, no typical characteristics known,
  fulfilling criteria C and D
• B. Head trauma with at least one of the
  following
• 1. Loss of consciousness for gt30 minutes
• 2. Glasgow Coma Scale (GCS) lt13
• 3. Post-traumatic amnesia for gt48 hours
• 4. Imaging demonstration of a traumatic brain
  lesion (cerebral hematoma, ICH and/or SAH, brain
  contusion and/or skull fracture)
• C. Headache develops within 7 days after head
  trauma or after regaining consciousness following
  head trauma
• D. Headache persists for gt3 months after head
  trauma

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HEADACHE ATTRIBUTED TO INTRACRANIAL NEOPLASM

• Headache occurs in 50 to 70 of those with brain
  tumors, but the presence of early morning severe
  headache with nausea and vomiting occurs in no
  more than 20 of patients.
• Rapidly growing tumors and those located in the
  posterior fossa are more likely to be associated
  with headache

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Mechanisms of Headache in Brain Tumors

• Traction of dura and large vessels
• Direct pressure on cranial and cervical nerve
  fibers
• The release of inflammatory/hormonal mediators
• Raised intracranial pressure

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Diagnostic Criteria for Headache Attributed to
Increased Intracranial Pressure or Hydrocephalus
Caused by Neoplasm

• A. Diffuse non-pulsating headache with at least
  one of the following characteristics and
  fulfilling criteria C and D
• 1. Associated with nausea and/or vomiting
• 2. Worsened by physical activity and/or maneuvers
  known to increase intracranial pressure (such as
  Valsalva maneuvers, coughing or sneezing)
• 3. Occurring in attack-like episodes
• B. Space-occupying intracranial tumor
  demonstrated by CT or MRI and causing
  hydrocephalus
• C. Headache develops and/or deteriorates in close
  temporal relation to the hydrocephalus
• D. Headache improves within 7 days after surgical
  removal or volume-reduction of tumor

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Diagnostic criteria for Headache Attributed
Directly to Neoplasm

• A. Headache with at least one of the following
  characteristics and fulfilling criteria C and D
• 1. Progressive
  3. Worse in the morning
• 2. Localized
  4. Aggravated by coughing
  or bending forward
• B. Intracranial neoplasm shown by imaging
• C. Headache develops in temporal relation to the
  neoplasm
• D. Headache resolves within 7 days after surgical
  removal of neoplasm or treatment with
  corticosteroids

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Pain-Sensitive Structures of the Head

• Dura
• Dural veins and arteries
• Intracranial arteries
• Cranial nerves V, VII, IX, X
• Cervical root C13
• Periosteum of the skull
• Scalp
• Scalp muscles
• Scalp vessels
• Sinuses

• Eyes
• Ears
• Teeth and gums
• Carotid and vertebral arteries
• Cervical spine
• Cervical muscles and tendons
• Pain-Insensitive Structures
• Parenchyma
• Pia, ventricles
• Skull, cervical spine

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Intracranial Pressure and Herniation
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POST-DURAL (POST-LUMBAR) PUNCTURE HEADACHE

• Bier in 1898 first reported post-LP headaches.
• Headache occurs in as many as 60 of patients who
  undergo LP.
• Most post-LP headaches are gone in a week or
  two they commonly occur the day after the LP

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In 1891 Heinrich Quincke, of Kiel, Germany,
introduced Lumbar Puncture as we know it today
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Risk Factors for Post-LP Headache

• Headache before LP
• Patients with a lower body mass index
• Younger female patients
• Length of recumbency following LP does not
  influence the chance, neither does opening
  pressure, LP position, and the amount of CSF
  removed.
• Small-gauge atraumatic needles reduce the risk of
  post-LP headache.

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Post-dural (Post-lumbar) Puncture Headache
Diagnostic criteria

• A. Headache that worsens within 15 minutes after
  sitting or standing and improves within15 minutes
  after lying, with at least one of the following
  and fulfilling criteria C and D
• 1. Neck stiffness
  4. Photophobia
• 2. Tinnitus
  5. Nausea
• 3. Hypacusia
• B. Dural puncture has been performed
• C. Headache develops within 5 days after dural
  puncture
• D. Headache resolves either
• 1. Spontaneously within 1 week
• 2. Within 48 hours after effective treatment of
  the spinal fluid leak (usually by epidural blood
  patch)