HEADACHE - one of the most common complaints, often reflecting the problems in the body as a whole. Headaches can be divided into primary and secondary. For 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, injuries, metabolic disorders, intoxications, or certain medications.
Although serious organic diseases are detected during examination in no more than 5% of patients who are treated for headaches, they should be excluded in the first place.
One of the most common causes of symptomatic headaches is cerebrovascular disease. A sudden intense diffuse or occipital headache is characteristic of subarachnoid hemorrhage, usually caused by rupture of cerebral artery aneurysm. Patients call this pain the most severe 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 join (stiff neck, Kernig and Brudzinsky symptoms - see Meningitis).
Diffuse or local intense headache, combined with depression of consciousness and focal neurological symptoms (weakness or numbness in the limbs, impaired speech and coordination), may be a sign of intracerebral hemorrhage, ischemic stroke, venous sinus thrombosis.
In patients with hypertension, pain is usually localized in the occipital region and often occurs in the early 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 decrease in headaches. Persistent headaches in the temporal and frontal areas in patients older than 60 years of age, occurring against the background of general weakness, subfebrile condition, weight loss, and an increase in ESR, can be caused by temporal arteritis.
A headache associated with an increase in intracranial pressure (intracranial hypertension) may be an early sign of a tumor , brain abscess, hematoma and other volume formations, as well as hydrocephalus. The pain is more often diffuse, but sometimes it can correspond to the localization of the volumetric lesion. At first, the headache is episodic in nature and occurs in the morning, but gradually increases and becomes constant. The pain is often accompanied by vomiting, which can occur without previous nausea, intensifies with coughing, sneezing, tilting the head and can wake a person at night. Characterized by a gradual increase in pain, the appearance of asymmetry of reflexes, oculomotor disturbances, decreased memory, intelligence, behavior change. When examining the fundus, stagnant disks of the optic nerves can be detected.
Pain arising from physical exertion, straining, coughing, tilting the head is often caused by tumors of the posterior cranial fossa or craniovertebral anomalies. But sometimes a short-term (lasting several minutes) intense headache in this situation occurs without any intracranial pathology.
Pain associated with. inflammatory or degenerative lesions of the cervical spine (cervicogenic headache), usually localized in the cervical-occipital region, but often spreads to the frontotemporal region, as well as to the shoulder and arm. The pain is usually of moderate intensity and intensifies with head movement, prolonged stay in an uncomfortable position, with palpation of the muscles of the cervical-occipital region. The mobility of the cervical spine is limited. In a small part of patients, posterior cervical sympathetic syndrome is detected, characterized by a combination of migraine-like headache with autonomic disorders (pupil dilatation, facial hyperhidrosis, less often pupil constriction and ptosis), dizziness, blurred vision. Pain in the cervical-occipital region can also be a manifestation of neuralgia of the occipital nerves, abnormalities or tumors of the craniovertebral transition.
A 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 affected sinus. Headache occurs regularly with rhinitis and sinusitis of an allergic nature. Pain in the temporomandibular joint syndrome is provoked by chewing, yawning, wide opening or tightening 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, to the lower jaw, and is accompanied by clicking or limiting movements in the joint.
With a combination of a pulsating periorbital headache with eye pain, hyperemia and soreness of the eyeball, visual impairment, nausea, and vomiting, acute angle-closure glaucoma should be excluded. To do this, measure intraocular pressure. Chronic headache is often the result of improper selection of glasses with refractive errors or prolonged eye strain, while it occurs in the afternoon and is accompanied by a feeling of tension in the neck muscles and tightening of the scalp. Short-term intense pain in the periorbital region, in the area of the nasal dorsum and throat can be observed with external hypothermia of the head or with cold food. Such pain often occurs in patients with migraine and is associated with irritation of Cold receptors (in particular, the posterior pharyngeal wall).
Post-traumatic headache may persist for several months or years after a traumatic brain injury. The pain often develops after a mild injury and is usually accompanied by a decrease in attention, memory, psycho-emotional disorders, dizziness, increased fatigue, and sleep disturbance. The pain is often diffuse, dull and worse with physical exertion. In some patients, pain is associated with damage to the cervical spine as a result of the so-called whiplash injury. If the pain grows and confusion, drowsiness, anisocoria , asymmetry of reflexes or other focal symptoms appear, it is necessary to exclude a chronic subdural hematoma (see. Craniocerebral trauma).
A headache is the inevitable companion of any febrile infections. However, the appearance of meningeal symptoms, repeated vomiting, depression of consciousness, or focal neurological disorders requires the exclusion of meningitis, encephalitis, or brain abscess.
Headache is an almost constant symptom of intoxication and metabolic disorders. Diffuse breaking or throbbing pain often occurs with withdrawal symptoms in alcoholics or people with caffeine addiction. Usually, withdrawal pain intensifies with a change in body position, accompanied by nausea, profuse sweating, and other autonomic symptoms.
Headache can also be caused by vasodilators (nitrates, chimes, calcium antagonists), non-steroidal anti-inflammatory and antihistamines, barbiturates and other anticonvulsants, ergot drugs, corticosteroids, estrogens, lipid-lowering and antibacterial agents.
Primary forms of headache are found in clinical practice much more often than secondary ones. These include tension headache and migraine , as well as more rare cluster headache and chronic paroxysmal hemicrania.
A tension headache can occur at any age, but more often begins at 25 to 30 years. Usually it is of moderate intensity, lasts from several tens of minutes to several days and does not increase with physical exertion. The pain is almost always bilateral, localized in the occipital, temporal or frontal areas, has a compressive or compressive character and is not accompanied by vomiting. Sometimes anorexia , nausea , photophobia or phobia are possible. Often, patients with difficulty describe their feelings and often complain not of true pain, but of a feeling of heaviness or pressure, a feeling of a helmet that pulls one's head together. In most patients, pain in the muscles of the scalp and collar region can be detected. Anxiety and depression, pathology of the cervical spine and temporomandibular joint, constant use of large doses of analgesics, caffeine, benzodiazepines and barbiturates contribute to the chronicity of headaches.
Cluster ("bundle") headache occurs mainly in men. This is a one-sided, very painful ("suicidal") pain, localized in the periorbital and frontotemporal region, sometimes extending to the back of the head and neck. The pain occurs paroxysmally, the duration of attacks is from 15 minutes to 3 hours. They occur once or several times a day, mainly at night, for several weeks or months. Exacerbations are divided by months-long or long-term remissions. Horner syndrome, redness of the eyes, lacrimation, discharge from the nose, and nasal congestion are usually observed during the attack on the pain side. Cluster headache is close to chronic paroxysmal hemicrania, but this condition is more often observed in women and is characterized by shorter, but more frequent seizures, as well as the absence of distinct remissions and a good effect as a result of using indomethacin.
Diagnosis. Particular caution is necessary in the following cases: 1) newly arising intense headaches or a change in the nature of pre-existing pains; 2) headaches, increasing over several days or weeks; 3) headaches, aggravated by physical exertion, straining, coughing, sneezing, bending; 4) headaches that arose against a background of fever, nausea, vomiting and meningeal syndrome; 5) headaches, accompanied by the appearance of neurological or mental disorders (speech, coordination, weakness or numbness in the limbs, seizures, increased drowsiness, decreased memory and intelligence, personality changes). The examination includes measurement of blood pressure, examination of the fundus, x-ray of the skull, cranio-vertebral junction and cervical spine, ultrasound dopplerography. When examining the fundus, congestive optic nerves can be detected, indicating intracranial hypertension, and in acute cases, retinal hemorrhages, which serve as a sign of rupture of aneurysm or malignant arterial hypertension. During auscultation of the head, noise may be detected, indicating arteriovenous malformation. If sinusitis is suspected, consultation with an otorhinolaryngologist and radiography of the paranasal sinuses are necessary. In cases of acute intense headaches, especially accompanied by meningeal syndrome, a lumbar puncture is indicated, which allows diagnosing meningitis or subarachnoid hemorrhage (volumetric formation should be excluded first).
The treatment of secondary headaches involves primarily an effect on their cause. With primary headaches, it is necessary to influence all factors that can provoke a headache. The patient needs to 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 per day more often than 3 days a week. For tension headache, nonpharmacological treatment methods are effective: neck and collar zone massage, reflexology, autogenic training, etc. In the chronic form of tension headache, the prophylactic use of tricyclic antidepressants is indicated. With severe anxiety, a short course of benzodiazepines (diazepam, alprazolam) is indicated. Non-steroidal anti-inflammatory drugs (aspirin, naproxen) and muscle relaxants - tizanidine (sirdalud) also have a preventive effect in case of chronic headache. In cases of cervicogenic headaches, the use of non-pharmacological methods (blockade of the occipital nerves, massage, extension of the cervical spine, manual therapy) in combination with a short course of non-steroidal anti-inflammatory drugs and muscle relaxants (tizanidine, baclofen) has a beneficial effect. In violation of the function of the temporomandibular joint in some cases correction of the bite is necessary, a combination of non-steroidal anti-inflammatory drugs with muscle relaxants, antidepressants and physiotherapeutic procedures also has a certain effect. Headaches caused by physical stress, if they are not caused by organic pathology, can be relieved by the prophylactic use of anaprilin (20 - 80 mg) or indomethacin (25 - 75 mg).