Headache
Common – 75% females and 50% of males usually get at least one headache a month – up to 90% have not sought medical help. F>M.
Can be primary (eg cluster, migraine, tension) or secondary to an underlying organic pathology (eg space occupying lesion, raised intracranial pressure, arterial hypertension, meningitis, temporal arteritis).
Migraine Headache:
Classically characterised by episodes of recurrent throbbing head pain associated with an aura – usually unilateral and with visual disturbances; usually begin in teenagers, but can start as late as 40 yrs; usually familial
Migraine with aura (classic migraine):
• visual aura precedes headache by up to 20 minutes (in both or one eye) – usually waviness, foggy, zigzag lines or blurred vision; less common auras are sensory (especially parathesia in limbs) or motor weakness
• headache lasts 6 –48 hours; most commonly 2 to 4 a month
• may also get vomiting, nausea, sensitivity to light (photophobia) and sound (phonophobia), irritability, malaise
• definite pathophysiological mechanism not yet known; most likely vascular factors involved, though neural hypothesis proposed
Migraine without aura (common migraine):
get headache without prodrome of visual disturbance; usually have at least one of nausea, vomiting and/or photophobia
usually has a longer course than classic migraine
Other types of migraine:
• transformational migraine (transforms or evolves from intermittent attacks to almost daily headaches)
• ophthalmoplegic migraine
• hemiplegic migraine
• aphasic migraine
• menstrual migraine
Treatment:
• identification of inciting factors control if possible; common exacerbating foods include those rich in tyramine (eg cheese, red wine), containing monosodium glutamate (eg Mexican food), alcoholic drinks and caffeinated beverages.
• initial management of acute attack – rest in quiet dark room; avoid movement, reading or watching TV; use aspirin or paracetamol; if vomiting prochlorperazine suppository or IM metoclopramide; if these measures unsuccessfully previously ergotamine at onset of prodrome
• non-pharmacological approaches can help (but not as effective as pharmacological approached) – biofeedback, stress management, stop smoking
• pharmacological prophylaxis (if frequent and severe) – aspirin; propranolol; pizotifen; amitriptyline
Cluster Headache (migrainous neuralgia):
Boring, sharp, piercing pain of rapid onset (in contrast to throbbing pain of migraine – though may be considered a variant of migraine headache) – may get nausea and vomiting. Usually unilateral – located around eye, temple, forehead or cheek region. Mean age of onset is around 25 yrs. M6x>F. Last 15 mins-2-3 hours. No prodromal symptoms. Usually distributed into clusters (eg daily for 3 weeks to 3months, then remitting for months to years). Treatment – 10 mins of oxygen is effective; ergotamine, methysergide, propranolol, verapamil. Subcutaneous injections of sumatriptan can halt attacks.
Tension/Psychogenic Headache:
This type of headache is usually experienced by almost everybody at some stage. Dull constant pain with feeling of pressure and tightness – bilateral and diffuse distribution (most commonly in temporal region). F>M. Sporadic. Pain often less noticeable when occupied with some activity. Usually less painful in morning becomes worse during day. Usually bilateral. Often have neck and scalp muscle tightness – relieved by massage. Headache usually relieved by aspirin or acetaminophen often do not seek medical help. Stress management and muscle relaxation techniques often help. If severe, amitriptyline can be used.
Trigeminal neuralgia:
Brief lancinating/stabbing pain in distribution of fifth (trigeminal) cranial nerve – lasts several seconds to minutes; more common on right side; usually middle aged to elderly; often have trigger points on face and pain may be stimulated by touching them.
Treatment – phenytoin, carbamazepine, baclofen; surgical decompression of the trigeminal ganglion.
Other types of headaches:
• atypical facial pain (often associated with a depressive illness)
• ‘ice cream’ headache (sharp and severe’; lasts a few minutes; triggered by cold stimuli)
• ice-pick headache (sudden stabbing pains around temple that last 2-3 seconds occurring many times a day; poorly understood; responds to indomethacin)
• temporal/giant cell arteritis (usually severe pain in one temple)
• postcoital headache (intense, pulsatile, sudden onset of pain in entire head following orgasm)
• post-concussion syndrome (diffuse head pain; irritable; poor concentration; may persist for up to 12 months)
• exertional headache (bursting pain; lasts several minutes; pain is generalised)
• idiopathic intracranial hypertension (IIH)
• intracranial mass lesions (symptoms are similar to other types of headaches, but often awake early in morning with headache; may have focal neurological abnormalities)
Headaches due to increased intracranial pressure usually worse in morning and get better during day; may have vomiting in morning; worse when bend forward, when coughing or straining; analgesics are effective; usually a mild dull ache.
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