Headache

Causes of headache are summarized in Table 34-1. First step—distinguish serious

from benign etiologies. Symptoms that raise the suspicion for a serious

cause are listed in Table 34-2; serious causes are summarized in Table 34-3.

Intensity of head pain rarely has diagnostic value; most pts who present to

emergency ward with worst headache of their lives have migraine. Headache

location can suggest involvement of local structures (temporal pain in giant cell

arteritis,facial pain in sinusitis). Ruptured aneurysm (instant onset), cluster

headache (peak over 3–5 min),and migraine (onset over minutes to hours)

differ in time to peak intensity. Provocation by environmental factors suggests

a benign cause.

Evaluation

Complete neurologic exam is essential first step. If exam is abnormal or if

serious underlying cause is suspected for any reason,an imaging study (CT or

MRI) is indicated. Lumbar puncture is required when meningitis (stiff neck,

fever) is a possibility.

Migraine

Classic Migraine Onset usually in childhood,adolescence, or early adulthood;

however,initial attack may occur at any age. Family history often positive. More frequent in women. Classic triad: premonitory visual (scotoma or

scintillations) sensory or motor symptoms,unilateral throbbing headache, nausea

and vomiting. Photo- and phonophobia common. Vertigo may occur. Focal

neurologic disturbances without headache or vomiting (migraine equivalents)

may also occur. An attack lasting 2–6 h is typical,as is relief after sleep. Attacks

may be triggered by wine, cheese, chocolate,contraceptives,stress, exercise, or

travel.

Common Migraine Unilateral or bilateral headache with nausea,but no

focal neurologic symptoms. Moderate-to-severe head pain,pulsating quality, unilateral,worse with activity; associated with photophobia, phonophobia, multiple

attacks. More common in women. Onset more gradual than in classic

migraine; duration 4–72 h.

International Headache Society Classification of Headache

1. Migraine

Migraine without aura

Migraine with aura

Ophthalmoplegic migraine

Retinal migraine

Childhood periodic syndromes that may be precursors to or

associated with migraine

Migrainous disorder not fulfilling above criteria

2. Tension-type headache

Episodic tension-type headache

Chronic tension-type headache

3. Cluster headache and chronic paroxysmal hemicrania

Cluster headache

Chronic paroxysmal hemicrania

4. Miscellaneous headaches not associated with structural

lesion

Idiopathic stabbing headache

External compression headache

Cold stimulus headache

Benign cough headache

Benign exertional headache

Headache associated with sexual activity

5. Headache associated with head trauma

Acute posttraumatic headache

Chronic posttraumatic headache

6. Headache associated with vascular disorders

Acute ischemic cerebrovascular disorder

Intracranial hematoma

Subarachnoid hemorrhage

Unruptured vascular malformation

Arteritis

Carotid or vertebral artery pain

Venous thrombosis

Arterial hypertension

Other vascular disorder

7. Headache associated with nonvascular intracranial

disorder

High CSF pressure

Low CSF pressure

Intracranial infection

7. Headache associated with nonvascular intracranial disorder (cont.)

Sarcoidosis and other noninfectious inflammatory diseases

Related to intrathecal injections

Intracranial neoplasm

Associated with other intracranial disorder

8. Headache associated with substances or their withdrawal

Headache induced by acute substance use or exposure

Headache induced by chronic substance use or exposure

Headache from substance withdrawal (acute use)

Headache from substance withdrawal (chronic use)

9. Headache associated with noncephalic infection

Viral infection

Bacterial infection

Other infection

10. Headache associated with metabolic disorder

Hypoxia

Hypercapnia

Mixed hypoxia and hypercapnia

Hypoglycemia

Dialysis

Other metabolic abnormality

11. Headache or facial pain associated with disorder of facial or cranial

structures

Cranial bone

Eyes

Ears

Nose and sinuses

Teeth,jaws, and related structures

Temporomandibular joint disease

12. Cranial neuralgias, nerve trunk pain, and deafferentation pain

Persistent (in contrast to ticlike) pain of cranial nerve origin

Trigeminal neuralgia

Glossopharyngeal neuralgia

Nervus intermedius neuralgia

Superior laryngeal neuralgia

Occipital neuralgia

Central causes of head and facial pain other than tic douloureux

13. Headache not classifiable

TREATMENT

Three approaches to migraine treatment: nonpharmacologic (Table 34-4),

drug treatment of acute attacks (Table 34-5),and prophylaxis (Table 34-6).

Drug treatment necessary for most migraine pts,but avoidance or management of environmental triggers is sufficient for some. General principles of

pharmacologic treatment: (1) response rates vary from 60–90%; (2) initial

drug choice is empirical—influenced by patient age,coexisting illnesses, and

side effect profile; (3) efficacy of prophylactic treatment may take several

months to assess with each drug; (4) when an acute attack requires additional

medication 60 min after the first dose,then the initial drug dose should be

increased for subsequent attacks. A staged approach to treatment is outlined

in Table 34-7. Mild-to-moderate acute migraine attacks often respond to overthe-

counter (OTC) NSAIDs when taken early in the attack. Triptans are

widely used also,but recurrence of head pain after the first dose (40–78%)

is a major limitation. There is less frequent headache recurrence when using

ergots,but more frequent side effects. For prophylaxis, amitriptyline is a good

first choice for young people with difficulty falling asleep; verapamil is often

a first choice for prophylaxis in the elderly.

Headache Symptomsthat Suggest a SeriousUnderlying Disorder

“Worst” headache ever

First severe headache

Subacute worsening over days or weeks

Abnormal neurologic examination

Fever or unexplained systemic signs

Vomiting precedes headache

Induced by bending,lifting, cough

Disturbs sleep or presents immediately upon awakening

Known systemic illness

Onset after age 55

Nonpharmacologic Approachesto Migraine

Identify and then avoid trigger factors such as:

Alcohol (e.g.,red wine)

Foods (e.g.,chocolate,certain cheeses,monosodium glutamate,nitratecontaining

foods)

Hunger (avoid missing meals)

Irregular sleep patterns (both lack of sleep and excessive sleep)

Organic odors

Sustained exertion

Acute changes in stress levels

Miscellaneous (glare,flashing lights)

Attempt to manage environmental shifts such as:

Time zone shifts

High altitude

Barometric pressure changes

Weather changes

Assess menstrual cycle relationship

Tension Headache Common in all age groups. Pain is holocephalic,described

as pressure or a tight band. May persist for hours or days. Often related

to stress; responds to relaxation and OTC analgesics (Table 34-8). Amitriptyline

may be helpful for prophylaxis. Distinction from common migraine may be

difficult.

Cluster Headache Characterized by episodes of recurrent,nocturnal, unilateral,

retroorbital searing pain. Typically, a young male (90%) awakens 2–

4 h after sleep onset with severe pain,unilateral lacrimation, and nasal and

conjunctival congestion. Visual complaints,nausea,or vomiting are rare. Pain lasts 30–120 min but tends to recur at the same time of night or several times

each 24 h over 4–8 weeks (a cluster). Diurnal periodicity (recurrent pain during

the same hour each day of the cluster) occurs in 85%. A pain-free period of

months or years may be followed by another cluster of headaches. Alcohol

provokes attacks in 70%. Prophylaxis with lithium (600–900 mg qd) or prednisone

(60 mg for 7 days followed by a rapid taper). Ergotamine,1-mg suppository 1–2 h before expected attack,may prevent daily episode. High-flow

oxygen (9 L/min) or sumatriptan (6 mg SC) is useful for the acute attack.

Other Headaches

Post-Concussion Headache Common following motor vehicle collisions,

other head trauma; severe injury or loss of consciousness often not present.

Symptoms of headache,dizziness,vertigo,impaired memory, poor concentration,

irritability; typically remits after several weeks to months. Neurologic examination

and neuroimaging studies normal. Not a functional disorder; cause

unknown.

Lumbar Puncture Headache Typical onset 24–48 h after LP; follows 10–

30% of LPs. Positional: onset when pt sits or stands,relief by lying flat. Most cases remit spontaneously in _1 week. Intravenous caffeine (500 mg IV,repeat

in 1 h if dose ineffective) successful in 85%; epidural blood patch effective

immediately in refractory cases.

Cough Headache Transient severe head pain with coughing,bending,lifting,

sneezing, or stooping; lasts from seconds to several minutes; men _

women. Usually benign,but posterior fossa mass lesion in _25%. Consider

brain MRI.

Facial Pain

Most common cause of facial pain is dental; triggered by hot,cold,or sweet

foods. Exposure to cold repeatedly induces dental pain. Trigeminal neuralgia

consists of paroxysmal,electric shock–like episodes of pain in the distribution

of trigeminal nerve; occipital neuralgia presents as lancinating occipital pain.

These disorders are discussed in Chap. 194.