Headache

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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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