Headache

Headache is one of the most frequent complaints that neurologists and general practitioners face. International Society IHS identifies more than 160 varieties of cephalogy.

Headache is one of the most common reasons for seeking medical help. Most relapsing headaches can be classified as a primary headache (ie not associated with explicit structural abnormalities). The primary headache is a migraine (with or without aura), a headache (episodic or chronic), a tension headache (episodic or chronic), chronic paroxysmal hemicrania and persistent hemicrania continue. A newly emerging, unfamiliar persistent headache may be secondary, due to various intracranial, extracranial and systemic disorders.

[1], [2], [3], [4], [5]

Causes

Pain in the region of the cranial vault (up from the eyebrows and to the back of the head) and inside the brain cranium is called cephalgia, cranialgia. Pain in the face  - prozopalgia - is caused by neuralgia and neuritis of the cranial nerves (trigeminal, glossopharyngeal), vegetative ganglia (ciliary, pharyngeal, ear), cervical sympathetic ganglia, including stellate, sinusitis, arthrosis-arthritis of temporomandibular joints, arteries, diseases of teeth and gums (odontogenic prozopalgia).

Headache is not a separate disease, but a symptom, which is sometimes a very important sign that warns of serious pathology. Sometimes a headache can be determined by a laboratory test or by neuroimaging. If this reason is established, the pain in the head often (but not always) can be eliminated with adequate therapy of the underlying disease. If the source that causes pain is not established or its treatment does not lead to regress, then there is a need for symptomatic pharmacotherapy and related disorders. Pharmacotherapy is mainly of an empirical nature and involves the use of various means. Headache of chronic form can require not only therapeutic measures aimed at stopping a pain attack, but also preventive therapy aimed at reducing the frequency and severity of seizures. The mechanism of action of many therapeutic agents has not been sufficiently studied. Headache is a new state and as the understanding of the pathogenesis of primary forms deepens, conditions are created for developing more effective and safe drugs.

[6], [7], [8], [9], [10]

What's happening?

Headache and its pathogenesis have not been studied enough. It can be caused by irritation of sensitive structures of the head and neck from tension, pressure, displacement, stretching and inflammation. Along with the nerves and vessels of the external soft parts of the head, some parts of the dura mater, venous sinuses with their larger inflows, large vessels of the dura mater, and sensitive cranial nerves also have pain sensitivity. The very tissue of the brain, soft meninges and small blood vessels do not have pain sensitivity.

Headache can arise due to spasm, dilatation or traction of blood vessels; traction or displacement of the sinuses; compression, traction or inflammation of these cranial nerves; spasm, inflammation or trauma to the muscles and tendons of the head and neck; irritation of the meninges and increased intracranial pressure. The severity and duration of the attack, as well as localization, can provide valuable information for the diagnosis.

Pain in the head can be functional or organic. Organic headache, as a rule, will be associated with such neurological symptoms and signs as vomiting, fever, paralysis, paresis, convulsions, confusion, weakened consciousness, mood changes, visual disorders.

The headache is known to everyone, since childhood. The only exception is people with congenital insufficiency of sensitive neurons.

Painful receptors of sensory neurons are located in the dura mater, the sinuses of the dura mater, the duplication of the envelope in the sagittal venous sinus and the nasal conjecture of the cerebellum, the vessels. There are no painful receptors in the soft and arachnoid shells of the brain, ependyma, choroidal plexuses, and most areas of the parenchyma of the brain.

There are pain receptors in extracranial tissues: skin, aponeurosis, muscles of the head, nose, teeth, mucous membranes and periosteum of the jaws, nose, tender eye structures. There are few pain receptors in the veins of the head, bones and diploe. Neurons with pain receptors in the head tissues make up the sensitive branches of cranial nerves (V, V, X, X) and the first three spinal radic nerves.

Headache is the most frequent complaint that patients address to a doctor of any specialty and is the leading or only complaint for more than 45 different diseases: organic lesions of the nervous system (inflammatory, vascular, tumor, traumatic), arterial hypertension and hypotension of various genesis (nephrogenic, endocrine, psychogenic), neuroses, depression, etc., i.e., is a polyethiologic syndrome.

At the same time, a detailed explanation of the peculiarities of the pain syndrome helps both the topical diagnosis, as well as the pathogenetic diagnosis. When complaining about a headache, it is necessary to specify its nature, intensity, localization, duration and time of appearance, as well as provoking, enhancing or alleviating factors.

Localization and characteristics of headache

Patients often can not tell about the nature of pain. Therefore, it is important for the doctor to formulate specific questions correctly for clarifying the features using definitions like "pressing", "drilling", "brainwashing", "gnawing", "bursting", "squeezing", "shooting," "explosive," "tense" , "Throbbing", etc. Headache can cause minimal psychological discomfort or lead to loss of ability to work, a deterioration in the quality of life.

It is important to clarify the localization. An intense headache along the extracranial vessels is characteristic for arteritis (eg, temporal). If the sinuses of the paranasal sinuses, teeth, eyes, upper cervical vertebrae are affected, the pain is less clearly localized and can be projected into the forehead, upper jaw, orbit. With pathology in the posterior cranial fossa, the headache is localized in the occipital region, it can be one-sided. The supratentorial location of the pathological process causes pain in the frontal-temporal region of the corresponding side.

However, the localization may not coincide with the topic of the pathological process. For example, a headache in the forehead area can be with glaucoma, sinusitis, vertebral or basilar artery thrombosis, compression or irritation of cerebellar nest (Burdenko-Kramer's syndrome with a tumor, abscess of the cerebellum: pain in the eyeball, photophobia, blepharospasm, lacrimation, conjunctivitis, increased separation of mucus from the nose). Pain in the ear can indicate a disease of the ear itself or be reflected in the defeat of the pharynx, cervical muscles, cervical vertebrae, structures of the posterior cranial fossa. Periorbital and supraorbital headache indicates a local process, but may also be reflected in the exfoliating hematoma of the internal carotid artery at the neck level. Headache in the region of the crown or in both parietal areas occurs with sinusitis of the main and ethmoid bones, as well as with thrombosis of large veins of the brain.

There is a relationship between localization and the affected vessel. Thus, with the expansion of the middle meningeal artery, the headache is projected behind the eyeball and into the parietal region. With the pathology of the intracranial part of the internal carotid artery, as well as the proximal areas of the anterior and middle cerebral arteries, the headache is localized in the eye and the orbital region. Localization of the algebra usually depends on the stimulation of certain sensitive neurons: pain from the supratentorial structures irradiates in the anterior two-thirds of the head, i.e., into the innervation of the first and second branches of the trigeminal nerve; pain from the infratentorial structures is reflected in the crown and back of the head and neck through the upper cervical roots; when V, X, and X stimulate the cranial nerves, the pain radiates to the ear, the naso-orital zone, and the pharynx. When the disease of the teeth or temporomandibular joint pain can irradiate into the skull.

It is necessary to find out the variant of the beginning of the pain sensation, the time of its intensity change and the duration. Headache, which suddenly arose and is intense, growing within a few minutes, with a sensation of spilling heat (heat) is typical for subarachnoid hemorrhage (with a rupture of the vessel). Suddenly arising and increasing headache for tens of minutes and hours happens with migraine. If the headache has an increasing character and lasts for hours or for days - a sign of meningitis.

In terms of duration and flow peculiarities, there are 4 variants:

1. acute headache (single, short);
2. acute repetitive (with the presence of light intervals, is characteristic of migraine);
3. chronic progressive (with a tendency to increase, for example, with a tumor, meningitis);
4. chronic non-progressive headache (occurs daily or several times a week, does not change in severity over time - the so-called tension headache).

The most common headache arises from pathological processes that lead to deformation, displacement or dilatation of vessels or structures of the dura mater mainly on the basis of the brain.

It is interesting that an increase in intracranial pressure with the introduction of a sterile physiological solution subarachnoidally or intraventricularly does not lead to an attack, unless other mechanisms are included. Headache is a consequence of dilatation of intracranial and extracranial vessels on the background of possible sensitization. This is observed with the administration of histamine, alcohol, nitrates and other similar drugs.

Vascular expansion is observed with a significant increase in blood pressure against pheochromocytoma, malignant arterial hypertension, and sexual activity. The therapeutic effect in such cases has inhibitors of monoamine oxidase.

To reduce the threshold of pain sensitivity receptors of the vessels of the base of the brain and the dura mater (sensitization of blood vessels) and their expansion may result in a violation of the exchange of neurotransmitters, in particular serotonin receptors (5HT) in brain vessels and trigeminal neurons, and an imbalance in the work of opioid receptors around the Sylvian aqueduct and urea nuclei, which are part of the antinociceptive system and provide endogenous control over the formation of pain. Headache through vasodilation occurs with various common infections (influenza, acute respiratory infections, and so on).

In 1988, an international classification was adopted that helps the doctor correctly orientate in the examination and treatment of the patient. Headache in this classification is divided into the following groups:

1. migraine (without aura and with aura);
2. tension headache (episodic, chronic);
3. cluster (bundle) headache;
4. headache, not associated with structural lesions (from external compression, provoked by cold, with coughing, physical exertion, etc.);
5. headache associated with head trauma (acute and chronic post-traumatic headache);
6. headache associated with vascular disorders (ischemic vascular-cerebral disease, subarachnoid hemorrhage, arteritis, thrombosis of cerebral veins, arterial hypertension, etc.);
7. headache with intracranial non-vascular processes (with high or low cerebrospinal pressure, infection, tumor, etc.);
8. headache associated with taking or abolishing chemicals (nitrates, alcohol, carbon monoxide, ergotamines, analgesics, etc.);
9. headache in cases of extra-cerebral infectious diseases (viral, bacterial and other infections);
10. headache associated with metabolic disorders (hypoxia, hypercapnia, dialysis, etc.);
11. headache in the pathology of the neck, eyes, ears, nose, paranasal sinuses, teeth and other facial structures.

What if you have a headache?

The anamnesis and the results of an objective examination in most cases allow to presume a diagnosis and determine the further tactics of the patient's examination.

Anamnesis

Headache should be characterized by such parameters, which are important for the diagnosis, include the age of onset of headaches; frequency, duration, localization and intensity; factors that provoke, aggravate or alleviate pain; concomitant symptoms and diseases (eg, fever, neck stiffness, nausea, vomiting, mental changes, photophobia), as well as previous illnesses and events (eg head trauma, cancer, immunosuppression).

An episodic, relapsing, intense headache, starting in adolescence or early adulthood, is most likely primary. Unbearable (lightning-fast) pain in the head can indicate a subarachnoid hemorrhage. Daily subacute and progressive headache may be a symptom of volume formation. Headache, beginning after age 50 and accompanied by soreness in palpation of the scalp, pain in the mandibular joint during chewing and decreased vision, is most likely due to temporal arteritis.

Confusion, convulsive seizures, fever, or focal neurological symptoms indicate a serious cause that requires further examination.

The presence of concomitant pathology in an anamnesis can explain the cause of headaches: for example, recent head trauma, hemophilia, alcoholism or treatment with anticoagulants can cause subdural hematoma.

[11], [12], [13]

Clinical examination

It is necessary to perform a neurological examination, including ophthalmoscopy, assessment of mental status and checking meningeal symptoms. Recurrent episodic headache in patients who, at first glance, look healthy and do not have neurological abnormalities, is rarely caused by a serious cause.

Rigidity of the neck muscles during flexion (but not during rotation) indicates irritation of the brain membranes due to infection or subarachnoid hemorrhage; increased body temperature indicates infection, but a slight increase in temperature may accompany hemorrhage. Painfulness in the palpation of the vessels of the temporal region in most cases (> 50%) indicates a temporal arteritis. Edema of the optic discs indicates increased intracranial pressure, which may be due to malignant hypertension, neoplasm, or thrombosis of the sagittal sinus. Morphological changes (eg, tumors, strokes, abscess, hematoma) are usually accompanied by focal neurological symptoms or changes in mental status.

[14], [15], [16], [17], [18], [19]

Instrumental examination

Imaging methods and laboratory tests are necessary only in cases when the history or the results of the survey cause suspicion of the presence of pathology.

Patients who need urgent CT or MRI to detect hemorrhage and other morphological changes that cause headaches include those with: conditions such as

• suddenly developed headache;
• change in mental status, including convulsive seizures;
• focal neurological symptoms;
• edema of the optic disc;
• severe arterial hypertension.

Due to the fact that conventional CT can not completely exclude conditions such as subarachnoid hemorrhage, meningitis, encephalitis or inflammatory processes, a lumbar puncture is indicated for suspected cases.

Immediate, but not urgent, CT or MRI is required if the headache changes its habitual character, the first headache after 50 years, the presence of systemic symptoms (such as weight loss), the presence of secondary risk factors (such as cancer, HIV, trauma head) or chronic unexplained headaches. For these patients, MRI with gadolinium and magnetic resonance angiography or venography is preferred; MRI allows you to visualize a number of important potential causes of headaches that are inaccessible to CT (for example, carotid artery stenosis, cerebral venous thrombosis, pituitary apoplexy, vascular malformations, cerebral vasculitis, Arnold Chiari syndrome).

Intensive persistent headache is an indication for lumbar puncture to exclude chronic meningitis (eg, infectious, granulomatous, tumor).

Other diagnostic methods are used according to complaints and clinical picture to confirm or exclude specific causes (eg, determination of ESR for the exclusion of temporal arteritis, measurement of intraocular pressure in case of suspected glaucoma, dental x-rays if suspected tooth pulp abscess).