Headache and

Dizziness/Vertigo
Surat Tanprawate, MD, MSc(Lond.), FRCPT
Division of Neurology
Chaing Mai University
The Northern Neuroscience Centre
Chiang Mai University
NNC CMU
Worldwide prevalence of headache

Rigmor Jensen, The Lancet (2008)

The Northern Neuroscience Centre
Chiang Mai University
NNC CMU
Lifetime Prevalence of Headache
Type Prevalence (%)

Primary headache
TTH 78
Migraine 16

Secondary headache
Fasting
Nose/sinus disease 19
Head trauma 15
Non-vascular intracranial 4
disease (including brain 0.5
tumor)
Ramussen BK et al. J Clin Epi 1991
 Pain

Ren Descartes, French

Philosopher
31 March 1596 11 February 1650
 Understanding pain sensitive
structure in the head
Harold Wolff and Bronson Ray(1940)

Observe that the mechanical stimulation

of the brain parenchyma did not cause
pain in awake patients who were
undergoing craniotomies but that similar
stimulation of the meninges and cerebral
and meningeal blood vessels produced
severe, penetrating, ipsilateral headache

Ray, B.S. and H.G. Wolff. (1940). Experimental studies on headache. Pain-sensitive structures of the head and their
significance in headache. Arch. Surg. 41:813 - 856.
 Ray and Wolff method
Surgical exposure of structures within and outside the
cranium
The observation were recorded (localization, what kind
of stimulation) in operating room
30 patients with local anesthesia:
extra- and intracranial structure
: Scalp, galea, fascia, muscles, arteries, vein,
sinuses

Ray, B.S. and H.G. Wolff. (1940). Arch. Surg. 41:813 - 856
 Scalp, galea (epicranial aponeurosis), fascia,
muscles:
--150 observations, 30 subjects
--thermal,chemical, mechanical, electrical stimulation

Ventricles, aqueduct of Sylvius,

Choroid plexuses
--24 observations, 4 subjects
--a balloon placed through a small
opening into anterior horn and body
of lateral ventricle

Dural artery (middle meningeal artery):

--96 observations, 11 subjects
--stimuli: faradizing, distending, stroking, Ray and Wolff(1940)
stretching, crushing
Headache and Pain Sensitive Structure
Meninges

Venous sinus

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

Neural structure:
-glossopharyngeal n.
-trigeminal n.
-upper cervical n.

 International Classification of
Headache Disorder (ICHD-3 Beta)

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. Painful cranial
neuropathies, other facial pains,
http://ihs-classification.org
and other headaches
 Approach to
Headache disorder
 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
headache and headache headache
other TACs disorder disorder
History taking
History taking
History taking
History taking
 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
headache and headache headache
other TACs disorder disorder
 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

 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
Migraine
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
 Clinical Picture

Genetic

Trigger
factors

Environmental
factors
Migraine attack
 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
The Classic Migraine =
Migraine with aura
Teichopsia
(Greek for town
wall vision)

On a distinct form of
transient hemiopsia by
Dr. Hubert Airy in 1870.
 Migraine without aura

Migraine with typical aura needs 2 attacks

In children, the attack may last 1-72 hours
ICHD-III Cephalalgia.2014
Tension-type
headache
The Northern Neuroscience Centre
Chiang Mai University
NNC CMU
The term Tension-type headache
Previous used terms:

muscular contraction headache, psychogenic

headache, psychomyogenic headache, non-
migraineous headache

Term Tension-type

offer the heading underlining the uncertain

pathogenesis, but indicating that some kind of
mental or muscular tension may play a role
The Northern Neuroscience Centre
Chiang Mai University
Tension-type headache
Episodic
infrequent vs frequent
Chronic
Pericranial tenderness
with/without
NNC CMU
A. At least 10 episode of headache
B. Lasting from 30 minutes to 7 days
C. At least two of the following four
characteristics
1. bilateral location
2. pressing or tightening (non-pulsating)
quality
3. mild or moderate intensity
4. not aggravated by routing physical
activity such as walking or climbing stairs
D. Both of the following:
1. no nausea or vomiting
2. no more than one of photophobia or
photophobia
E. Not better accounted for by another
ICHD-3 diagnosis
The Northern Neuroscience Centre

NNC CMU
Chiang Mai University

Differential diagnosis issues

Secondary cause

Hypertension, metabolic, systemic, low/high CSF,

diffuse intracranial lesion, sleep apnea

TMJ disorder, cervicogenic headache

Myofascial pain syndrome, fibromyalgia

Primary headache - Migraine

The Northern Neuroscience Centre
Chiang Mai University
NNC CMU
TTH or Migraine

Mild

Moderate

Severe
Aura
Unilateral
Vomiting
Bilateral

Photophobia Aggravated
by activity
Nausea

Throbbing

Pressure

Tension-type
Migraine
headache
 Trigeminal Autonomic
Cephalalgia
The most severe headache ever
Trigeminal Autonomic Cephalalgia (TACs)

A group of primary headache disorders

characterized by, short-lasting, strictly unilateral
head pain that occurs in association with
ipsilateral cranial autonomic features

Cluster Headache (CH)

Paroxysmal Hemicrania (HC)
Short-lasting unilateral neuralgiform headache attack
with conjunctival injection and tearing/cranial autonomic
features (SUNCT/SUNA)
Hemicrania Continua (HC)
ICHD-III Beta 2013
ICHD-II 2004 CH ICHD-III Beta 2013 CH
criteria criteria

ICHD-II
ICHD-III Beta
 TACs subtypes

Longer name,
shorter duration

Prevalence 56/100,000 Very rare, not known Very rare, not known
Cohen AS. Headache 2007
 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 2014
-Headache attributed to ....
Part III. Painful cranial
neuropathies, other facial pains,
http://ihs-classification.org
and other headaches
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
ICHD-III beta
 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

 Classical trigeminal neuralgia

Symptomatic trigeminal neuralgia

TN caused by a demonstrable structural lesion
Vertigo/Dizziness
 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
 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, Menieres disease
 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
 Time course-onset
Lasting for day or longer
Peripheral: vestibular neuritis
Central: brainstem stroke, MS

Lasting for hours or minute

Peripheral: Menieres disease
Central: TIA, migraine, seizure

Lasting for second

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

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