Neil H. Raskin
D A BHADJA
FINAL YEAR BHMS
The quality, location, duration,
and time course of the
headache and the conditions
that produce, exacerbate, or
relieve it should be carefully
Pain intensity seldom has diagnostic value.
People respond to pain in a variety of ways
that range from overt histrionic behavior to
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.
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.
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.
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
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
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
Thus whereas most of the brain is insensitive to
electrode probing, a site in the midbrain
represents a possible source of headache
Headache can occur as the result of
1) distention, traction, or dilation of intracranial or extra
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
5) meningeal irritation and raised intracranial
6) possibly, perturbation of intracerebral serotonergic
VARIETIES OF HEADACHE
LUMBAR PUNCTURE HEADCHE
purulent sinusitis, bacterial
meningitis, and brain tumor
because of the clues
provided by the associated
symptoms and signs.
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,
®Migraine, by far the most common cause of
headache, is considered in detail in Chap.
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.
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
Many investigators believe that periodic tension
headache is biologically indistinguishable from
migraine (Chap. 364).
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
Nausea and stiff neck often accompany
headache, and occasional patients report
blurred vision, photophobia, tinnitus, and
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;
Following seemingly trivial head
injuries and particularly after rear- end
motor vehicle collisions, many patients
report varying combinations of
headache, dizziness, vertigo, and
Anxiety, irritability and difficulty with
concentration are other hallmarks of
Temporal (giant cell) arteritis is an
inflammatory disorder of arteries that
frequently involves the extra cranial carotid
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.
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
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
The term effort migraine has been
used for this syndrome to avoid the
ambiguous term exertional
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).
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.
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.
HEADACHE CAUSED BY
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
Many of the illnesses associated with human
immunodeficiency virus, and the acute blood
pressure elevations that occur in
pheochromocytoma and in malignant
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
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.