HEADACHE

HEADACHE is one of the most common complaints, often reflecting ill-being in the body as a whole. Headaches can be divided into primary and secondary. With primary headaches, the most thorough examination does not reveal any organic causes. Secondary, or symptomatic, headaches are the result of various neurological and somatic diseases, trauma, metabolic disorders, intoxication or taking certain medications.

Although serious organic diseases are detected on examination in not more than 5% of patients who are applying for headaches, they should be excluded first.

One of the most common causes of symptomatic headaches are cerebral vascular diseases. A sudden intense diffuse or occipital headache is characteristic of a subarachnoid hemorrhage, usually caused by rupture of an aneurysm of the cerebral artery. Patients call this pain the most powerful of all that they have ever experienced in life. It is often accompanied by vomiting and loss of consciousness. From the very beginning or after a short time, meningeal symptoms (stiff neck muscles, symptoms of Kernig and Brudzinsky - see Meningitis) are added.

Diffuse or local intense headache, combined with oppression of consciousness and focal neurological symptoms (weakness or numbness in the extremities, speech and coordination disorders) may be a sign of intracerebral hemorrhage, ischemic stroke, thrombosis of venous sinuses.

In patients with arterial hypertension, pain is usually localized in the occipital region and often occurs early in the morning. A clear connection between the appearance of a headache and a mild or moderate increase in blood pressure is usually not detected (pain naturally occurs only with a rapid rise in blood pressure above 200/120 mm Hg), although stabilization of blood pressure is often accompanied by a reduction in headaches. Persistent headaches in the temporal and frontal regions in patients older than 60 years, arising against a background of general weakness, subfebrile condition, weight loss, increased ESR, may be due to temporal arteritis.

Headache associated with increased intracranial pressure (intracranial hypertension) may be an early sign of a tumor , brain abscess, hematoma and other voluminous formations, as well as hydrocephalus. Pain more often diffuse, but sometimes it can correspond to localization of volumetric lesion. Initially, the headache is episodic and occurs in the morning, but gradually increases and becomes permanent. Pain is often accompanied by vomiting, which can occur without previous nausea, is worse when coughing, sneezing, tilting the head and can wake a person at night. Characteristic gradual increase in pain, the appearance of asymmetry reflexes, oculomotor disorders, memory loss, intelligence, behavior change. When examining the fundus, stagnant discs of the optic nerves may be detected.

The pain that occurs with physical stress, straining, coughing, and head inclinations is often caused by tumors of the posterior cranial fossa or craniovertebral anomalies. But sometimes an intermittent (lasting several minutes) intense headache in this situation arises without any intracranial pathology.

Pain associated with. Inflammatory or degenerative lesion of the cervical spine (cervicogenic headache), is usually localized in the cervico-occipital region, but often extends into the fronto-temporal region, as well as into the shoulder and arm. The pain is usually of moderate intensity and intensifies with the movement of the head, a prolonged stay in an uncomfortable position, with palpation of the muscles of the cervico-occipital region. The mobility of the cervical spine is limited. A small part of the patients shows a posterior cervical sympathetic syndrome, characterized by a combination of migraine-like headache and autonomic disorders (pupil dilatation, facial hyperhidrosis, less pupil narrowing and ptosis), dizziness, blurred vision. Pain in the cervico-occipital region may also be a manifestation of the neuralgia of the occipital nerves, anomalies or tumors of the craniovertebral junction.

Headache in the periorbital, frontal and parietal areas can be a sign of inflammation of the paranasal sinuses. Pain with sinusitis is usually accompanied by fever, nasal congestion, purulent discharge from it, flushing of the skin and soreness with percussion in the area of ​​the affected sinus. Headache regularly occurs with rhinitis and sinusitis of an allergic nature. Pain in the temporomandibular joint syndrome is provoked by chewing, yawning, wide opening or squeezing of the mouth. It is associated with an abnormal bite, inflammatory or degenerative changes in the joint. The pain is usually localized in the joint area, often radiating to the frontal and temporal region, into the lower jaw, and is accompanied by a click or restriction of movements in the joint.

When combining pulsating periorbital headache with pain in the eye, flushing and painfulness of the eyeball, visual disturbance, nausea, vomiting, it is necessary to exclude sharp closed-angle glaucoma. To do this, it is necessary to measure the intraocular pressure. Chronic headache is often the result of improper selection of glasses for refractive error or prolonged eye strain, and it occurs in the second half of the day and is accompanied by a feeling of tension in the muscles of the neck and tightening the covers of the head. Short-term intense pain in the periorbital region, in the region of the back of the nose and throat, can be observed with external hypothermia of the head or the intake of cold food. Such pain is more common in migraine patients and is associated with irritation of the cold receptors (in particular, the posterior pharyngeal wall).

Post-traumatic headache may persist for several months or years after traumatic brain injury. The pain develops more often after a mild trauma and is usually accompanied by a decrease in attention, memory, psychoemotional disorders, dizziness, increased fatigue, sleep disturbance. Pain is often diffuse, blunt and worse with physical exertion. In some patients, pain is associated with damage to the cervical spine as a result of a so-called whiplash injury. If pain increases and confusion, drowsiness, anisocoria , asymmetry of reflexes or other focal symptoms occur, chronic subdural hematoma must be eliminated (see Cranial Brain Trauma).

Headache is the inevitable companion of any infections that occur with fever. However, the appearance of meningeal symptoms, repeated vomiting, oppression of consciousness or focal neurological disorders requires the exclusion of meningitis, encephalitis or abscess of the brain.

Headache is almost a constant symptom of intoxication and metabolic disorders. Diffusive lomyaschee or throbbing pain often occurs with withdrawal symptoms in alcoholics or persons with caffeine dependence. Usually abstinence pain increases with a change in body position, accompanied by nausea, profuse sweating and other vegetative symptoms.

Headache can also be caused by vasodilators (nitrates, curantyl, calcium antagonists), nonsteroidal anti-inflammatory and antihistamines, barbiturates and other anticonvulsants, ergot preparations, corticosteroids, estrogens, lipid-lowering and antibacterial agents.

Primary forms of headache are more common in clinical practice than secondary ones. These include tension headache and migraine , as well as rarer cluster headache and chronic paroxysmal hemicrania.

Tension headache can appear at any age, but more often starts in 25 to 30 years. Usually it is of moderate intensity, lasting from several tens of minutes to several days and does not increase with physical activity. The pain is almost always bilateral, localized in the occipital, temporal or frontal areas, has a pressing or compressive nature and is not accompanied by vomiting. Sometimes anorexia , nausea , light or phobia are possible. Often, patients with difficulty describe their feelings and often complain not of real pain, but of a feeling of heaviness or pressure, a feeling of a helmet pulling the head. In most patients, it is possible to identify the soreness of the muscles of the scalp and the collar area. Chronization of the headache contributes to anxiety and depression, the pathology of the cervical spine and temporomandibular joint, constant use of large doses of analgesics, caffeine, benzodiazepines and barbiturates.

Cluster ("beam") headache is found mainly in men. This one-sided very painful ("suicidal") pain localized in the periorbital and frontotemporal region, sometimes giving back to the neck and neck. The pain arises paroxysmally, the duration of attacks from 15 minutes to 3 hours. They come one or several times a day, mostly at night, for several weeks or months. Exacerbations are divided by many months or years of remission. During an attack on the side of pain, Horner's syndrome, redness of the eye, lacrimation, nasal discharge and nasal congestion are usually noted. Cluster headache is similar to chronic paroxysmal hemicrania, but this condition is more common in women and is characterized by less prolonged but more frequent attacks, as well as a lack of distinct remissions and a good effect as a result of the use of indomethacin.

Diagnosis. Special caution is necessary in the following cases: 1) newly emerged intense headaches or a change in the character of pre-existing pain; 2) headaches that build up over several days or weeks; 3) headaches, aggravated by physical exertion, straining, coughing, sneezing, tilting; 4) headaches caused by fever, nausea, vomiting and meningeal syndrome; 5) headaches accompanied by the appearance of neurological or psychiatric disorders (speech disorders, coordination, weakness or numbness in the limbs, convulsive seizures, increased drowsiness, decreased memory and intelligence, personality changes). The examination includes measurement of blood pressure, examination of the fundus, radiography of the skull, craniovertebral transition and cervical spine, ultrasonic dopplerography. When examining the fundus, stagnant discs of the optic nerves can be identified, indicating intracranial hypertension, and in acute cases - bleeding in the retina, which serve as a sign of rupture of an aneurysm or malignant hypertension. With auscultation of the head, noise can be detected, indicating arteriovenous malformation. If you suspect a sinusitis consultation of the otorhinolaryngologist and radiography of the paranasal sinuses is necessary. In cases of acute intense headaches, especially those accompanied by meningeal syndrome, a lumbar puncture is indicated, which makes it possible to diagnose meningitis or subarachnoid hemorrhage (the volume formation should be excluded first).

Treatment of secondary headaches involves primarily an effect on their cause. At primary headaches it is necessary to influence all factors, capable to provoke a headache. The patient should give up smoking, reduce the consumption of alcohol, caffeine, provide adequate physical activity. The dose of analgesics should be limited - the patient should not take more than two tablets of drugs a day more often than 3 days a week. At a headache of a strain, non-pharmacological methods of treatment are effective: neck and collar zone massage, reflexotherapy, autogenic training, etc. In the chronic form of tension headache, a prophylactic administration of tricyclic antidepressants is indicated. With severe anxiety, a short course of benzodiazepines (diazepam, alprazolam) is indicated. Preventive action in chronic tension headaches also have nonsteroidal anti-inflammatory drugs (aspirin, naproxen) and muscle relaxants - tizanidine (sirdalud). In cases of cervicogenic headaches, the use of non-pharmacological methods (occipital blockade, massage, cervical traction, manual therapy) in combination with a short course of non-steroidal anti-inflammatory drugs and muscle relaxants (tizanidine, baclofen) has a beneficial effect. If the temporomandibular joint function is disturbed, correction of occlusion is necessary in some cases, a combination of non-steroidal anti-inflammatory drugs with muscle relaxants, antidepressants and physiotherapy procedures also has a certain effect. Headaches caused by physical stress, if they are not caused by organic pathology, can facilitate the preventive administration of anaprilin (20 - 80 mg) or indomethacin (25 - 75 mg).