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  1. 1. HEADACHE - Neil H. Raskin Prepared by D A BHADJA FINAL YEAR BHMS MEHSANA
  2. 2. GENERAL CONSIDERATIONS The quality, location, duration, and time course of the headache and the conditions that produce, exacerbate, or relieve it should be carefully reviewed.
  3. 3. intensity Pain intensity seldom has diagnostic value. People respond to pain in a variety of ways that range from overt histrionic behavior to stoicism. how pain disturbs day-to-day function. Patients entering emergency departments with the most severe headache of their lives usually have migraine. Meningitis, subarachnoid hemorrhage, and cluster headache also produce intense cranial pain. Contrary to common belief, the headache produced by a brain tumor is not usually distinctive or severe.
  4. 4. location Lesions of paranasal sinuses, teeth, eyes, and upper cervical vertebrae induce less sharply localized pain, but pain that is still referred in a regional distribution. Intracranial lesions in the posterior fossa cause pain that is usually occipitonuchal, and supratentorial lesions most often induce frontotemporal pain.
  5. 5. Duration and time-intensity A ruptured aneurysm results in head pain that peaks in an instant, thunderclap-like; much less often, unruptured aneurysms may signal their presence in the same way. 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 is characteristic of headaches produced by brain tumors.
  6. 6. Recurrent headache provocation by red wine, sustained exertion, organic odors, hunger, lack of sleep, weather change, and menses. A history of amenorrhea or galactorrhea should lead one to question whether the polycystic ovary syndrome or a prolactin- secreting pituitary adenoma is the source of headache.
  7. 7. The analysis of facial pain requires a different approach. Trigeminal and less commonly glossopharyngeal neuralgia are frequent causes of facial pain (see Chap. 372). "Neuralgias" are painful disorders characterized by paroxysmal, fleeting, often electric shock-like episodes that are often caused by demyelinating lesions of nerves
  8. 8. PAIN-SENSITIVE STRUCTURES OF THE HEAD the scalp and aponeurotica, middle meningeal artery, dural sinuses, falx cerebri, and the proximal segments of the large pial arteries. The ventricular ependyma, choroid plexus, pial veins, and much of the brain parenchyma are pain-insensitive. Thus whereas most of the brain is insensitive to electrode probing, a site in the midbrain represents a possible source of headache generation.
  9. 9. Headache can occur as the result of 1) distention, traction, or dilation of intracranial or extra cranial arteries; 2) traction or displacement of large intracranial veins or their dural envelope; 3) compression, traction, or inflammation of cranial and spinal nerves; 4) spasm, inflammation, or trauma to cranial and cervical muscles; 5) meningeal irritation and raised intracranial pressure; and 6) possibly, perturbation of intracerebral serotonergic projections.
  12. 12. purulent sinusitis, bacterial meningitis, and brain tumor because of the clues provided by the associated symptoms and signs.
  13. 13. MIGRAINE A useful definition of migraine is a benign and recurring syndrome of headache, nausea, vomiting, and/or other symptoms of neurological 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) and its deactivators (sleep, pregnancy, exhilaration, sumatriptan). ®Migraine, by far the most common cause of headache, is considered in detail in Chap. 364.
  14. 14. CLUSTER HEADACHE The most common form of this syndrome is manifested by one to three short-lived daily attacks of periorbital pain over a 4- to 8- week interval followed by a pain-free interval that averages 1 year. The painful attacks are often associated with a homolateral red, tearing eye, nasal stuffiness, and ptosis. ®This subject is further discussed in Chap. 364.
  15. 15. TENSION HEADACHE The term tension headache is still commonly used to describe a chronic head pain syndrome characterized by tight bandlike discomfort. Patients may report that the 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. In some patients, anxiety or depression coexist with tension headache. Many investigators believe that periodic tension headache is biologically indistinguishable from migraine (Chap. 364).
  16. 16. LUMBAR PUNCTURE HEADACHE Headache following lumbar puncture (Chap. 360) usually begins within 48 h but may be delayed for up to 12 days. Its incidence is between 10 and 30 percent. Head pain is dramatically positional; it begins when the patient sits or stands upright; there is relief upon reclining or with abdominal compression. Nausea and stiff neck often accompany headache, and occasional patients report blurred vision, photophobia, tinnitus, and vertigo.
  17. 17. Loss of cerebrospinal fluid (CSF) volume decreases the brain's supportive cushion, so that when a patient is upright there is probably dilation and tension placed on the brain's anchoring structures, Treatment with intravenous caffeine sodium benzoate given over a few minutes as a 500-mg dose will promptly terminate headache in 75 percent of patients;
  18. 18. POSTCONCUSSION HEADACHES Following seemingly trivial head injuries and particularly after rear- end motor vehicle collisions, many patients report varying combinations of headache, dizziness, vertigo, and impaired memory. Anxiety, irritability and difficulty with concentration are other hallmarks of this syndrome.
  19. 19. TEMPORAL ARTERITIS Temporal (giant cell) arteritis is an inflammatory disorder of arteries that frequently involves the extra cranial carotid circulation. This is a common disorder of the elderly; its average annual incidence is 77:100,000 in individuals aged 50 and older. Typical presenting symptoms include headache, polymyalgia rheumatica (Chap. 319), jaw claudication, fever, and weight loss. Headache is the dominant symptom and often appears in association with malaise and muscle aches.
  20. 20. COUGH HEADACHE A male-dominated (4:1) syndrome, cough headache is characterized by transient, severe head pain upon coughing, bending, lifting, sneezing, or stooping. Head pain persists for seconds to a few minutes. Headache is usually diffuse but is lateralized in about one-third of patients. The incidence of serious intracranial structural anomalies causing this condition is about 25 percent; the Arnold-Chiari malformation (Chap. 373) is a common cause.
  21. 21. Many patients with migraine note that attacks of headache may be provoked by sustained physical exertion, such as during the third mile of a 5-mile run. Such headaches build up over hours, in contrast to cough headache. The term effort migraine has been used for this syndrome to avoid the ambiguous term exertional headache.
  22. 22. COITAL HEADACHE This is another male-dominated (4:1) syndrome. Attacks occur periorgasmically, are very abrupt in onset, and subside in a few minutes if coitus is interrupted. These are nearly always benign events and usually occur sporadically; if they persist for hours or are accompanied by vomiting, subarachnoid hemorrhage must be excluded (Chap. 366).
  23. 23. BRAIN TUMOR HEADACHE About 30 percent of patients with brain tumors consider headache to be their chief complaint. The head pain syndrome is usually nondescript¾an intermittent deep, dull aching of moderate intensity, which may worsen with exertion or change in position and may be associated with nausea and vomiting. This pattern of symptoms results from migraine far more often than from brain tumor. Headache of brain tumor disturbs sleep in about 10 percent of patients. Vomiting that precedes the appearance of headache by weeks is highly characteristic of posterior fossa brain tumors. ®A detailed discussion of brain tumors can be found in Chap. 375.
  24. 24. PSEUDOTUMOR CEREBRI Headache, clinically resembling that of brain tumor, is a common presenting symptom of pseudotumor cerebri, an unusual disorder of raised intracranial pressure probably resulting from impaired CSF absorption by the arachnoid villi. Transient visual obscurations, and papilledema with enlarged blind spots and loss of peripheral visual fields, are additional manifestations. Most patients are young, female, and obese.
  25. 25. HEADACHE CAUSED BY SYSTEMIC ILLNESS There is hardly any illness that is never manifested by headache; however, some illnesses are characteristically associated with headache. These include infectious mononucleosis, systemic lupus erythematosus, chronic pulmonary failure with hypercapnia (early morning headaches), Hashimoto's thyroiditis, inflammatory bowel disease Many of the illnesses associated with human immunodeficiency virus, and the acute blood pressure elevations that occur in pheochromocytoma and in malignant hypertension.
  26. 26. Approach to the Patient In general, acute, severe headache with stiff neck and fever suggests meningitis and without fever suggests subarachnoid hemorrhage; in the former case, lumbar puncture is mandatory, whereas in the latter case a neuroimaging procedure (CT) is the study of choice. Acute persistent headache and fever are often the manifestations of an acute systemic viral infection; if the neck is supple in such a patient, lumbar puncture may be deferred.