Headache

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. Affecting up to 10% of Americans, they’re more common in females and have a strong familial incidence.

Causes

Most chronic headaches result from tension — muscle contraction — that may be caused by emotional stress, fatigue, menstruation, or environmental stimuli (such as noise, crowds, and 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; and muscle spasms of the face, neck, or shoulders.

In addition, headaches may be caused by vasodilators (such as nitrates, alcohol, and histamines), systemic disease, hypoxia, hypertension, head trauma and tumor, intracranial bleeding, abscess, and aneurysm.

Migraine headache

The cause of migraine headache is unknown, but a genetic link has been identified. These headaches are associated with constriction and dilation of intracranial and extracranial arteries initiated by neurons in the brainstem. Certain biochemical abnormalities are thought to occur during a migraine attack. They include local leakage of a vasodilator polypeptide called neurokinin through the dilated arteries as an inflammatory response and a decrease in the plasma level of serotonin.

Foods associated with migraine headache include aged or processed cheese and meats, alcoholic beverages (particularly red wine), food additives (such as monosodium glutamate), chocolate- and caffeine-containing foods, and nuts. Changes in the weather pattern, menstrual cycle fluctuations, sleep pattern changes, and too much or too little exercise as well as glaring lights and fatigue can also trigger a migraine headache. In addition, one of the more common causes of a recurring headache is the rebound effect that occurs when the original treatment used to get rid of the headache triggers the next episode (as with narcotics).

Headache pain

Pain may emanate from the pain-sensitive structures of the skin, scalp, muscles, arteries, and veins; cranial nerves V, VII, IX, and X; and cervical nerves 1, 2, and 3. Intracranial mechanisms of headache include traction or displacement of arteries, venous sinuses, or venous tributaries and inflammation or direct pressure on the cranial nerves with afferent pain fibers.

Signs and symptoms

Migraine headaches and muscle contraction headaches have different signs and symptoms.

Migraine headache

Initially, a migraine headache usually produces unilateral, pulsating pain that later becomes more generalized. The headache is 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 headache, page 364.)

Muscle contraction headache

A muscle contraction headache produces 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, the muscle contraction headache may result in neurologic deficits, such as paresthesia and muscle weakness; narcotics fail to relieve the pain in these cases. If the headache is caused by a tumor, pain is most severe when the patient awakens.

Diagnosis

An accurate 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, and tender spots (especially after trauma).

A 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).

Most patients may be diagnosed by a thorough history and physical examination. Magnetic resonance imaging, computed tomography scans, lumbar puncture, and serology may be beneficial. Neurologic deficits, such as stroke or brain tumors; metabolic processes, such as thyroid disease or diabetes; and an aneurysm must be ruled out if the headache is explosive and “the worst” in their lives.

Treatment

Depending on the type of headache, treatment interventions range from relaxation techniques, massage, and biofeedback to pharmacologic agents. Tricyclic antidepressants, beta-adrenergic blockers, and anticonvulsants may be prescribed for headache prevention; nonsteroidal anti-inflammatory drugs (NSAIDs), combination NSAIDs with caffeine, ergotamines, and dopamine antagonists  may be used for abortive measures. Narcotic agents are generally avoided or may be limited to twice weekly.

Abortive therapy using the synthetic form of serotonin (sumatriptan) is available in an oral form and as a nasal spray and can easily be carried for immediate use.

Other measures include identification and elimination of causative factors, stressors, or stimuli that might trigger an attack such as in the migraine-type headache. Diet history and examination of lifestyle patterns may help identify causative agents.

Special considerations

❑ Headaches seldom require hospitalization unless they’re caused by a serious disorder. If that’s the case, direct your care to the primary problem.

❑ Obtain a complete patient history, including duration and location of the headache, time of day it usually begins, nature of the pain, the concurrence of headache with other symptoms such as blurred vision, and precipitating factors, such as tension, menstruation, loud noises, menopause, alcohol use, use of medications such as hormonal contraceptives, and prolonged fasting.

Clinical tip  Have the patient keep a journal describing the events surrounding the headache. This can be used as a guide for the patient to avoid precipitating factors.

❑ Advise the patient 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.

❑ Bear in mind that the patient with a migraine headache usually needs to be hospitalized only if nausea and vomiting are severe enough to induce dehydration and, possibly, shock.

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Book Source Details

• Book Title: Handbook of Diseases
• Author(s): Springhouse
• Year of Publication: 2003
• Copyright Details: Handbook of Diseases, Copyright © 2003 Lippincott Williams & Wilkins.

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Copyright Details: Handbook of Diseases, Copyright © 2008 Williams & Wilkins.

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• Back to symptom: Earache: Introduction (review 186 causes)
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More About This Book: Title: Handbook of Diseases Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2003 ISBN: 1-58255-266-5

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