Headache and

Dizziness/Vertigo
Surat Tanprawate, MD, MSc(Lond.), FRCPT
Division of Neurology
Chaing Mai University

15/13/2011
Thursday, December 15, 2011
 Pain

René Descartes, French

Philosopher
31 March 1596 – 11 February 1650

Thursday, December 15, 2011

 Headache and Pain Sensitive Structure
Meninges

Venous sinus

Artery:
-dural a.
-carotid a.
-basilar a.

Neural structure:
-glossopharyngeal n.
-trigeminal n.
-upper cervical n.
Thursday, December 15, 2011
 International Classification of
Headache Disorder-2004

Part 1. The primary headaches

- Migraine, TTH, CH and other
TACs, and other primary
headache disorder
Part II. The secondary International Classification
headaches of
Headache Disorder 2004
-Headache attributed to ....
Part III. Cranial neuralgias,
central and primary facial pain
http://ihs-classification.org
and other headaches
Thursday, December 15, 2011
 Approach to
Headache disorder

Thursday, December 15, 2011

 Patient presents with
complaint of a headache
Red flag signs

Critical first step: (+)

Hx taking, physical exam
Investigation

Red flag signs or alarming

signs

Meets criteria for primary

headache disorder?
(-) (+)

Migraine Tension-type
headache headache

Other (rare) Secondary

Cluster Chronic daily headache headache
headache and
other TACs headache (CDH) disorder disorder
Thursday, December 15, 2011
 History taking

Thursday, December 15, 2011

 History taking

Thursday, December 15, 2011

 History taking

Thursday, December 15, 2011

 History taking

Thursday, December 15, 2011

 Patient presents with
complaint of a headache
Red flag signs

Critical first step: (+)

Hx taking, physical exam
Investigation

Red flag signs or alarming

signs

Meets criteria for primary

headache disorder?
(-) (+)

Migraine Tension-type
headache headache

Other (rare) Secondary

Cluster Chronic daily headache headache
headache and
other TACs headache (CDH) disorder disorder
Thursday, December 15, 2011
 Alarming signs and
symptoms

• “Alarming s/s suggest the possibility of

secondary headache

• The studies
• Headache sample (specific or non-
specific)

• Pool analyzed data => guideline

Thursday, December 15, 2011

 Focal neurologic s/s
Abnormal neurological other than typical visual
examination or sensory aura

Papilledema
Normal neurological
Neck stiffness
examination

Temporal Concurrent Provoking

Age
profile event activity

Age> 50 Worsening headache Pregnancy, post Triggered by cough,

-Mass lesion, SDH, partum exertion or Valsava
MOH -Cerebral vein -SAH, mass lesion
thrombosis, carotid
dissection, pituitary
apoplexy
Sudden onset
Worse in the
-SAH, ICH, mass morning
lesion (posterior -IICP
fossa) Headache with
cancer, HIV, systemic
illness (fever,
arteritis, collagen Worse on awakening
vascular disease) -Low CSF pressure

Thursday, December 15, 2011

 Patient presents with
complaint of a headache
Red flag signs

Critical first step: (+)

Hx taking, physical exam
Investigation

Red flag signs or alarming

signs

Meets criteria for primary

headache disorder?
(-) (+)

Migraine Tension-type
headache headache

Other (rare) Secondary

Cluster Chronic daily headache headache
headache and
other TACs headache (CDH) disorder disorder
Thursday, December 15, 2011
 Description and Criteria
http://ihs-classification.org

Description

Criteria

Thursday, December 15, 2011

 Migraine
• Epidemiology and problematic
concern
• Clinical and
pathophysiological ground
• Management strategies

Thursday, December 15, 2011

 Prevalence of Migraine

Incidence of migraine by age and sex Adjusted prevalence of migraine by

geographic area and meta-analysis of
studies using IHS criteria

Steewart WF. Am J Epidemiol.1991;134:1111-1120

Thursday, December 15, 2011
 Population-based study
Only migraine without aura
Only migraine with aura
Both types

14%

19%

67%

Migraine without aura is more common

(previously called common migraine)
Launer LJ et al. Neurology 1999;53:537-42

Thursday, December 15, 2011

 Clinical Picture

Genetic

Trigger
factors

Environmental
factors
Migraine attack

Thursday, December 15, 2011

 Migraine with aura =
“Classic migraine”
"He seemed to see something
shining before him like a light,
usually in part of the right eye; at
the end of a moment, a violent pain
supervened in the right temple,
then in all the head and neck....
vomiting, when it became
possible, was able to divert the
pain and render it more moderate."

Thursday, December 15, 2011

 ʻʻTeichopsiaʼʼ
(Greek for ʻʻtown
wall visionʼʼ)

ʻʻOn a distinct form of

transient hemiopsiaʼʼ by
Dr. Hubert Airy in 1870.

Thursday, December 15, 2011

 The “Classic” Migraine =
Migraine with aura

Thursday, December 15, 2011

 Migraine triggers
Chronobiologic Physical
Diet
• Sleep (too much or too exertion
• Hunger little)

•
• Exercise
• Alcohol Schedule change
• Sex
• Additives
Environmental
• Certain foods factors
Stress and
• Light glare anxiety
Hormonal • Odors
change • Altitude Head
• Menstruation
• Weather change trauma

Thursday, December 15, 2011

 Migraine Aura Typical aura:
-Visual
99% 31% -Sensory
-Speech

6%

18%

n=163
Michael B. R. et al. Brain 1996: 119, 355-361
Thursday, December 15, 2011
 Mechanism of head pain
“Trigeminovascular system”

Thursday, December 15, 2011

 Migraine without aura

Migraine with typical aura needs 2 attacks

In children, the attack may last 1-72 hours
ICHD-II Cephalalgia.2004
Thursday, December 15, 2011
 Tension-type
headache
• Most common headache type

• Featureless headache, uncertain

pathophysiology (mental or muscular cause?)

• HRQoL of Headache

• ETTH > CTTH = EM > CM/TM

• When migraine become chronic, the

headacheʼs characters are similar to TTH

Thursday, December 15, 2011

 TTH diagnostic criteria

Thursday, December 15, 2011

 Trigeminal Autonomic
Cephalalgia
“The most severe headache ever”

Thursday, December 15, 2011

 TACs
“A group of primary headache disorders
characterized by strictly unilateral head
pain that occurs in association with
ipsilateral cranial autonomic features”

- Cluster headache (CH)

- Paroxysmal hemicrania (PH)

- Short-lasting unilateral neuralgiform headache

attacks with conjunctival injection and tearing/
cranial autonomic features (SUNCT/SUNA)
Thursday, December 15, 2011
 Cluster headache
Cluster headache
and others TACs
“Short lasting,
unilateral, severe
headache
accompanying with
autonomic symptoms”

ICHD-II Cephalalgia.2004
Thursday, December 15, 2011
 International Classification of
Headache Disorder-2004

Part 1. The primary headaches

- Migraine, TTH, CH and other
TACs, and other primary
headache disorder
Part II. The secondary International Classification
headaches of
Headache Disorder 2004
-Headache attributed to ....
Part III. Cranial neuralgias,
central and primary facial pain
http://ihs-classification.org
and other headaches
Thursday, December 15, 2011
 Cranial Neuralgias

• The presence of sudden, sharp, aching,

lancinating, burning, and stabbing pain
lasting from only a few seconds to less
than 2 min and recurring repeatedly
within short periods of time, which is
often triggered by sensory or
mechanical stimuli

Thursday, December 15, 2011

 ICHD-II, 2004

Thursday, December 15, 2011

 Trigeminal Neuralgia
• 70% of patients are older than 60 years at
onset

• Clinical hallmark:
• brief electric shock-like pains

• abrupt in onset and termination

• limited to the distributions of the trigeminal

nerve

• commonly stimuli: mechanical

Thursday, December 15, 2011

Thursday, December 15, 2011
 Classical trigeminal neuralgia

Symptomatic trigeminal neuralgia

“TN caused by a demonstrable structural lesion”

Thursday, December 15, 2011

 Vertigo/Dizziness

Thursday, December 15, 2011

Thursday, December 15, 2011
Thursday, December 15, 2011
Thursday, December 15, 2011
 Syndrome of vertigo: base
on connection
Major symptoms • Psychiatric symptoms:
• Vertigenous sensation • Fear
• Imbalance • Anxiety
• Nystagmus and • Hyperventilation
oscillopsia syndrome
• Autonomic dysfunction • Phobia
• N/V
• Palpitation
• Fluctuation in BP

Thursday, December 15, 2011

 Dizzy symptoms
Non-vertigenous
dizziness
• Syncope
• Disequilibrium
True vertigo • Ill-define symptoms

S/S Peripheral Central

Latency 0-40 sec No latency
Duration <1 min May persist
Fatiguability Yes No
Nystagmus direction Direction fixed, torsional, up, upper pole Direction changing variable
of eye toward ground
Intensity of S/S Severe vertigo, nystagmus, nausea Mild vertigo, less intense nystagmus,
rare nausea
reproducibility Inconsistent More consistent

•Otological disorder
•Neurological disorder
Identify causes •Systemic disorder

Thursday, December 15, 2011

 Dizzy symptoms
Non-vertigenous
dizziness
• Syncope
• Disequilibrium
True vertigo • Ill-define symptoms

S/S Peripheral Central

Latency 0-40 sec No latency
Duration <1 min May persist
Fatiguability Yes No
Nystagmus direction Direction fixed, torsional, up, upper pole Direction changing variable
of eye toward ground
Intensity of S/S Severe vertigo, nystagmus, nausea Mild vertigo, less intense nystagmus,
rare nausea
reproducibility Inconsistent More consistent

Most helper differential •Otological disorder

causes •Neurological disorder
Time course - onset Identify causes •Systemic disorder

Thursday, December 15, 2011

 Causes of vertigo
Peripheral vertigo Central vertigo
• Infection/inflammation Common is
– Peripheral vestibulopathy
Vestibular neuritis, acute neurolabyrinthitis • Tumor: CP angle tumor
Localized: CN7+8 affected: Ramsay Hunt
syndrome • Demyelinating: MS
Systemic: mump, measle, IM, URI
• Vascular: ischemia(VBI)
• Trauma: post-traumatic vertigo
• Local tumor • Posterior fossa lesion
• Vascular: rare • Migraine
• Metabolic/ toxic • Vertigenous epilepsy
– Aminoglycoside(rare)
• Other: BPPV, Meniereʼs disease

Thursday, December 15, 2011

 Systemic causes of vertigo and
dizziness
• Drugs
–AED, hypnotic, alcohol, analgesic
• Hypotension, presyncope
• Infectious disease
–Syphilis, viral, systemic infection
• Endocrine disease
–Diabetes, hypothyroidism
• Vasculitis
• Others: hematological, granulomatous disease,
systemic toxin

Thursday, December 15, 2011

 Time course-onset
Lasting for day or longer
• Peripheral: vestibular neuritis
• Central: brainstem stroke, MS

Lasting for hours or minute

• Peripheral: Meniere’s disease
• Central: TIA, migraine, seizure

Lasting for second

• Peripheral: BPPV

Thursday, December 15, 2011

 Surat Tanprawate, MD, MSc(Lond.), FRCP(T)
CertHE(Hist Med)
Neurology staff,
Division of Neurology, CMU
The Northern Neuroscience Center, CMU

Thank You for Your

Kind Attention
Thursday, December 15, 2011