Headache
Headache: Excerpt from Professional Guide to Diseases (Eighth Edition)
The most common patient complaint, headache usually occurs as a symptom of an underlying disorder. Ninety percent of all headaches are vascular, muscle contraction, or a combination; 10% are due to underlying intracranial, systemic, or psychological disorders. Migraine headaches, probably the most intensively studied, are throbbing, vascular headaches that usually begin to appear in childhood or adolescence and recur throughout adulthood.
Causes and incidence
Most chronic headaches result from tension (muscle contraction), which may be caused by emotional stress, fatigue, menstruation, or environmental stimuli (noise, crowds, or bright lights). Other possible causes include glaucoma; inflammation of the eyes or mucosa of the nasal or paranasal sinuses; diseases of the scalp, teeth, extracranial arteries, or external or middle ear; muscle spasms of the face, neck, or shoulders; and cervical arthritis. In addition, headaches may be caused by vasodilators (nitrates, alcohol, and histamine), systemic disease, hypoxia, hypertension, head trauma and tumor, intracranial bleeding, abscess, or aneurysm.
The cause of migraine headache is unknown, but it’s associated with constriction and dilation of intracranial and extracranial arteries. Certain biochemical abnormalities are thought to occur during a migraine attack. These include local leakage of a vasodilator polypeptide called neurokinin through the dilated arteries and a decrease in the plasma level of serotonin.
Headache pain may emanate from the pain-sensitive structures of the skin, scalp, muscles, arteries, and veins; cranial nerves V, VII, IX, and X; or cervical nerves 1, 2, and 3. Intracranial mechanisms of headaches include traction or displacement of arteries, venous sinuses, or venous tributaries and inflammation or direct pressure on the cranial nerves with afferent pain fibers.
Affecting up to 10% of Americans, headaches are more common in females and have a strong familial incidence.
Signs and symptoms
Initially, migraine headaches usually produce unilateral, pulsating pain, which later becomes more generalized. They’re commonly preceded by a scintillating scotoma, hemianopsia, unilateral paresthesia, or speech disorders. The patient may experience irritability, anorexia, nausea, vomiting, and photophobia. (See Clinical features of migraine headaches.)
Both muscle contraction and traction-inflammatory vascular headaches produce a dull, persistent ache, tender spots on the head and neck, and a feeling of tightness around the head, with a characteristic “hatband” distribution. The pain is usually severe and unrelenting. If caused by intracranial bleeding, these headaches may result in neurologic deficits, such as paresthesia and muscle weakness; narcotics may fail to relieve pain in these cases. If caused by a tumor, pain is most severe when the patient awakens.
Diagnosis
Diagnosis requires a history of recurrent headaches and physical examination of the head and neck. Such examination includes percussion, auscultation for bruits, inspection for signs of infection, and palpation for defects, crepitus, or tender spots (especially after trauma). Firm diagnosis also requires a complete neurologic examination, assessment for other systemic diseases — such as hypertension — and a psychosocial evaluation, when such factors are suspected.
Diagnostic tests include cervical spine and sinus X-rays, EEG, computed tomography scan — performed before lumbar puncture to rule out increased intracranial pressure (ICP) — or magnetic resonance imaging. A lumbar puncture isn’t done if there’s evidence of increased ICP or if a brain tumor is suspected because rapidly reducing pressure by removing spinal fluid can cause brain herniation.
Treatment
Depending on the type of headache, analgesics — ranging from aspirin to codeine or meperidine — may provide symptomatic relief. Other measures include identification and elimination of causative factors and, possibly, psychotherapy for headaches caused by emotional stress. Chronic tension headaches may also require muscle relaxants.
For migraine headaches, ergotamine alone or with caffeine may be an effective treatment. The Food and Drug Administration allows labeling of various analgesic preparations that include caffeine to state that they’re for the treatment of migraine headaches. Remember that these medications can’t be taken by pregnant women because they stimulate uterine contractions. These drugs and others, such as metoclopramide or naproxen, work best when taken early in the course of an attack. If nausea and vomiting make oral administration impossible, drugs may be given as rectal suppositories.
Drugs in the class of sumatriptan are considered by many clinicians to be the drug of choice for acute migraine attacks or cluster headaches. Drugs that can help prevent migraine headaches include antidepressants (such as nortriptyline or fluoxetine), beta blockers (propranolol), and calcium-channel blockers (verapamil). Corticosteroids provide short-term relief for some patients with cluster headaches.
Special considerations
Headaches seldom require hospitalization unless caused by a serious disorder. If that’s the case, direct your care to the underlying problem.
❑Obtain a complete patient history: duration and location of the headache; time of day it usually begins; nature of the pain; concurrence with other symptoms such as blurred vision; precipitating factors, such as tension, menstruation, loud noises, menopause, or alcohol; medications taken such as oral contraceptives; or prolonged fasting. Exacerbating factors can also be assessed through ongoing observation of the patient’s personality, habits, activities of daily living, family relationships, coping mechanisms, and relaxation activities.
❑Using the history as a guide, help the patient avoid exacerbating factors. Advise him to lie down in a dark, quiet room during an attack and to place ice packs on his forehead or a cold cloth over his eyes.
❑Instruct the patient to take the prescribed medication at the onset of migraine symptoms, to prevent dehydration by drinking plenty of fluids after nausea and vomiting subside, and to use other headache relief measures.
❑The patient with a migraine headache usually needs to be hospitalized only if nausea and vomiting are severe enough to induce dehydration and possible shock.
❑Avoid repeated use of narcotics if possible.
Pictures
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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