Headache

Daniel EshetuDaniel Eshetu

one of the most important symptoms in clinical medicine

As many as 90% of individuals have at least one headache per year

Severe, disabling headache is reported to occur at least annually by 40% of individuals worldwide

Headache is usually a benign symptom, but occasionally it is the manifestation of a serious illness:

- Brain tumor, subarachnoid hemorrhage, meningitis, or giant cell arteritis

In emergency settings, approximately 5% of patients with headache are found to have a serious underlying neurologic disorder

IHS 2004:

- primary- Secondary

Primary: headache and the associated symptoms are the disorder in itself

Secondary: caused by exogenous disorders

only certain cranial structures are sensitive to pain:

1. Skin, subcutaneous tissue, muscles, extra cranial arteries, periosteum of the skull

2. delicate structures of the eye, ear, nasal cavities, and para-nasal sinuses

3. Intracranial venous sinuses and their tributaries

4. Parts of the dura at the base of the brain and the arteries with in the dura and pia-arachnoid

5. The middle meningeal and superficial temporal arteries

6. The optic, oculomotor, trigeminal, glossopharyngeal, vagus and the first three cervical nerves

Structures which lack sensitivity:

- The bony skull

- much of the pia-arachnoid over the convexity of the brain

- the parenchyma of the brain

- the ependyma and choroid plexus

Distention, traction, or dilation of intracranial or extracranial arteries

Traction or displacement of large intracranial veins or their dural envelope

Compression, traction, or inflammation of cranial and spinal nerves

spasm, inflammation, or trauma to cranial and cervical muscles

Meningeal irritation and raised intracranial pressure

Other possible mechanisms such as activation of brainstem structures.

In dealing with any painful state determine:qualityseveritylocationdurationtime courseconditions that produce, exacerbate, or relieve it.

occasionally helpful for diagnosis

Most tension-type headaches are described as tight “bandlike” pain or as dull, deeply located, and aching pain

A throbbing quality and tight muscles about the head, neck, and shoulder girdle are common nonspecific accompaniments of migraine headaches.

rarely has diagnostic value

patient's perspective, it is the single aspect of pain that is most important

most patients entering emergency departments with the most severe headache of their lives usually have migraine

The headache produced by a brain tumor is not usually distinctive or severe.

may be informative

If the source is an extracranial structure, as in giant cell arteritis, the correspondence with the site of pain is fairly precise

Inflammation of an extracranial artery- causes pain and tenderness at the site of the vessel

CTD

Lesions of paranasal sinuses, teeth, eyes, and upper cervical vertebrae- localized pain

Intracranial lesions in the posterior fossa- cause occipitonuchal pain

supratentorial lesions most often induce frontotemporal pain

are diagnostically useful

A ruptured aneurysm results in head pain that peaks in an instant, thunderclap-like

Cluster headache attacks reach their peak over 3 to 5 min, remain at maximal levels for about 45 min, and then taper off

Migraine attacks build up over hours, are maintained for several hours to days, and are characteristically relieved by sleep

Sleep disruption and early morning headaches brain tumors or other disorders that produce increased intracranial pressure.

must be distinguished from headache

Trigeminal and, less commonly, glossopharyngeal neuralgia are frequent causes of facial pain

Neuralgias are painful disorders characterized by paroxysmal, fleeting, often electric shock–like episodes

frequently caused by demyelinating lesions of nerves

the trigeminal or glossopharyngeal nerves in cranial neuralgias

Certain maneuvers characteristically trigger paroxysms of pain

- However, the most common cause of facial pain by far is dental

- The effect of eating on facial pain may provide insight into its cause

- Is it the chewing, swallowing, or taste of the food that elicits pain?

- Chewing suggests trigeminal neuralgia, temporomandibular joint dysfunction, or giant cell arteritis (“jaw claudication”)

- Whereas swallowing and taste provocation suggest glossopharyngeal neuralgia

Patients who present with their first severe headache raise entirely different diagnostic possibilities than those with recurrent headaches over many years.

In new-onset and severe headaches- a potentially serious cause is considerably greater than in recurrent headache

an acute, new-onset headache- consider: - meningitis - subarachnoid hemorrhage, - epidural or subdural hematoma- glaucoma - purulent sinusitis

Clinical features of acute, new-onset headache caused by serious underlying conditions(Red Flags):“Worst” headache everFirst severe headacheSubacute worsening over days or weeksAbnormal neurologic examinationFever or unexplained systemic signsVomiting precedes headacheInduced by bending, lifting, coughDisturbs sleep or presents immediately upon awakeningKnown systemic illnessOnset after age 55

A complete neurologic examination is an essential first step in the evaluation

an abnormal examination should be followed by a computed tomography (CT) or a magnetic resonance imaging (MRI) study

As a screening procedure for intracranial pathology in this setting, CT and MRI methods appear to be equally sensitive

Cardiovascular and renal status by blood pressure monitoring and urine examination

Eyes by fundoscopy, intraocular pressure measurement, and refraction

Cranial arteries by palpation

And cervical spine by the effect of passive movement of the head and imaging

The psychological state of the patient should also be evaluated

Head pain and depression

Many patients in chronic daily pain cycles become depressed

Greater-than-chance coincidence of migraine with both bipolar and major depressive disorders

Meningitis: - Nuchal rigidity - headache - photophobia- prostration- may not be febrile. - Lumbar puncture is diagnostic.

Intracranial hemorrhage (SAH or IPH):

- Nuchal rigidity and headache

- may not have clouded consciousness or seizures.

- Hemorrhage may not be seen on CT scan.

- Lumbar puncture shows “bloody tap” that does not clear by the last tube.

- A fresh hemorrhage may not be xanthochromic.

Brain tumor:

- prostrating pounding headaches

- associated with nausea and vomiting

- suspected in progressively severe new “migraine” that is invariably unilateral

Temporal arteritis:

- unilateral pounding headache

- Onset - older patients (>50 years)

- frequently associated with visual changes

- The erythrocyte sedimentation rate is the best screening test and is usually markedly elevated (i.e., >50)

- Definitive diagnosis can be made by arterial biopsy.

Glaucoma:

- consists of severe eye pain

- May have nausea and vomiting

- The eye is usually painful and red

- The pupil may be partially dilated.

systemic illnesses

idiopathic intracranial hypertension

Cough

Lumbar puncture

Post - concussion

Coital headache

CLINICAL VARIETIES OF RECURRENT HEADACHES

TENSION-TYPE HEADACHE:

- A chronic head pain syndrome characterized by bilateral tight, bandlike discomfort

- Head feels as if it is in a vise or that the posterior neck muscles are tight

- The pain typically builds slowly, fluctuates in severity, and may persist more or less continuously for many days

- Exertion does not usually worsen the headache

- The headache may be episodic or chronic (i.e., present >15 days per month).

- Tension-type headache is common in all age groups, and females tend to predominate

- In some patients, anxiety or depression coexist with tension headache

The 2nd most common cause of headache in clinical practice

afflicts approximately 15% of women and 6% of men- In Ethiopia: 4.2% Vs 1.7%

a benign and recurring syndrome of headache, nausea, vomiting, and/or other symptoms of neurologic dysfunction in varying admixtures

Migraine can often be recognized by its

- Activators: red wine, menses, hunger, lack of sleep, glare, estrogen, worry, perfumes, let-down periods

- Deactivators: sleep, pregnancy, exhilaration, triptans

- Migraine without aura

- Migraine with aura

- ‘Ophthalmoplegic migraine’

-  Retinal migraine

- Childhood periodic syndromes that may be precursors to or associated with migraine – eg cyclical vomiting

- Migrainous disorder not fulfilling above criteria

Migraine with Aura (Classic Migraine)A. At least two attacks that fulfill criterion B

B. At least three of the four characteristics:1)one or more reversible aura symptoms indicating focal cerebral or brainstem dysfunction

2) at least one aura develops gradually over more than 4 minutes and no single aura lasts longer than 60 minutes.

CTD3)headache begins during aura or follows with a symptom-free interval of less than 60 minutes

C. An appropriate history, physical, and diagnostic tests that exclude related organic disease

A distinctive and treatable vascular headache syndrome

The episodic type:

- most common

- characterized by one to three short-lived attacks of periorbital pain per day over a 4- to 8-week period, followed by a pain-free interval that averages 1 year

The chronic form:

- is characterized by the absence of sustained periods of remission

- may begin de novo or several years after an episodic pattern has become established

Each type may transform into the other

Men are affected seven to eight times more often than women

Hereditary factors are usually absent

Onset is generally between ages 20 and 50

Clinical Features :

- Periorbital or, less commonly, temporal pain begins without warning and reaches a crescendo within 5 min

- It is often excruciating in intensity and is deep, nonfluctuating, and explosive in quality

Only rarely is it pulsatile

Pain is strictly unilateral and usually affects the same side in subsequent months

Attacks last from 30 min to 2 h

There are often associated symptoms of homolateral lacrimation, reddening of the eye, nasal stuffiness, lid ptosis, and nausea

Alcohol provokes attacks in about 70% of patients but ceases to be provocative when the bout remits

This on-off vulnerability to alcohol is pathognomonic of cluster headache

Only rarely do foods or emotional factors precipitate pain, in contrast to migraine.

There is a striking periodicity of attacks in at least 85% of patients

At least one of the daily attacks of pain recurs at about the same hour each day for the duration of a cluster bout

Onset is nocturnal in about 50% of the cases, and then the pain usually awakens the patient within 2hrs of falling asleep.

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