Headaches

Almost every person experiences headaches repeatedly throughout their life. In most cases, they do not pose a serious danger and are a characteristic sign of overexertion or general fatigue of the body. However, in some cases, headaches may indicate quite serious pathologies that require qualified medical care.

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Headaches associated with vascular diseases

Headaches often occur as a result of a decrease or increase in blood pressure. With low blood pressure, headaches are usually dull, pressing, and can be localized in the area of the eyes and bridge of the nose, at the base of the neck. Sometimes they are paroxysmal in nature, accompanied by pulsation in the temporal region or in the crown area. The normalization of blood pressure in hypotension is facilitated by the use of caffeine (contained in such drugs as citramon, pyramein, caffetamin, askofen), as well as regular stay in the fresh air.

High blood pressure is often accompanied by such a condition as severe headaches, which may be accompanied by nosebleeds and dizziness. The danger of this disease is that it significantly increases the risk of stroke. For the treatment of high blood pressure, drugs are prescribed that are part of the group of diuretics, ACE inhibitors, angiotensin receptor blockers, beta-blockers. The use of such drugs is possible only as prescribed by a doctor, taking into account the individual characteristics of the body, the etiology of the disease and age factors. With a sharp increase in pressure, it is necessary to take a diuretic tablet, for example, Triphas, Furosemide. It is also advisable to have pharmadipine (take no more than three to four drops orally) and captopril in the first aid kit.

Arterial hypertension can cause headaches if:

• diastolic pressure rapidly increases by more than 25% from the initial value; the constant level of diastolic blood pressure is 120 mmHg;
• headaches occur against the background of acute hypertensive encephalopathy or if the increase in blood pressure occurs against the background of eclampsia;
• These headaches are relieved by drugs that normalize blood pressure.

Acute cerebrovascular accidents (especially hemorrhagic strokes, subarachnoid hemorrhage) are accompanied by headaches, which usually last for several weeks. The causes of these headaches are usually beyond doubt. In patients with a history of stroke, headaches are usually caused by other factors, particularly psychogenic ones. Often, other possible forms of headache are underestimated in these patients: migraine, tension headache, medication overuse and psychogenic (depression) headaches.

Diagnostic criteria for temporal arteritis:

• age 50 years and older;
• the patient talks about a new type of local headache;
• tension of the temporal artery and a decrease in its pulsation;
• increase in ESR to 50 mm per hour and higher;
• arterial biopsy reveals necrotizing
• arteritis.

Headaches in non-vascular intracranial diseases

Brain tumors are usually accompanied by focal neurological symptoms, signs of increased intracranial pressure, and a corresponding picture on computed tomography and magnetic resonance imaging.

Infectious intracranial processes (encephalitis, meningitis, abscesses) are accompanied by general infectious manifestations, symptoms of irritation of the meninges, and inflammatory changes in the cerebrospinal fluid.

Regardless of the nature of the indicated diseases, three mandatory criteria for the diagnosis of such cephalgias are proposed:

1. The clinical picture of the disease must include symptoms and signs of intracranial pathology;
2. Paraclinical examination methods reveal deviations confirming this pathology;
3. Headaches are assessed by the patient and the doctor as a new symptom (not typical for the patient before) or as a new type of headache (the patient says that his head began to hurt “differently”, and the doctor notes a change in the nature of the headache).

Headaches associated with diseases of the skull

Diagnostic criteria:

1. There should be clinical and paraclinical indications of diseases of the skull, eyes, ears, nose, lower jaw and other cranial structures.
2. Headache is localized in the area of the affected facial or cranial structures and spreads to surrounding tissues.
3. Headaches disappear after 1 month of successful treatment or spontaneous resolution of the indicated diseases.

Migraine headaches

A disease such as migraine is accompanied by quite severe paroxysmal headaches. It is believed that this pathology is associated with hereditary factors. A migraine attack and, accordingly, headaches can be provoked by prolonged exposure to the sun, in a poorly ventilated room, insufficient sleep and rest, the onset of menstruation in women, too sharp exposure to irritants such as noise, bright light, as well as a state of excitement and mental strain. Headaches with migraine can be accompanied by the appearance of luminous dots before the eyes, have a pulsating nature, are localized more often in one part of the head, although it can spread to both halves. Severe headaches can persist for up to several hours, during an attack the patient is recommended to observe silence and rest. After the attack has passed, the person usually feels completely healthy. To relieve pain, such drugs as paracetamol, analgin, aspirin can be used. Also in the complex therapy of migraine, the drug migraineol, sedalgin, metamizole, sumatriptan, vitamins, minerals, etc. are used. The choice of drugs for the treatment of migraine can only be made by a doctor based on the full symptoms of the disease and taking into account the individual characteristics of the body.

Migraine headaches without aura

The main diagnostic criteria for migraine without aura:

1. The patient must have at least five headache attacks lasting from 4 to 72 hours.
2. Headaches must have at least two of the following characteristics:
   • unilateral localization; pulsating character;
   • moderate or severe intensity (interfering with normal daily activities);
   • headache worsens with normal physical activity or walking.
3. There must be at least one of the following symptoms during the headache:
   • nausea and/or vomiting; photophobia or phonophobia.
4. The neurological status is normal, and the examination does not reveal any organic disease that could cause headache.

Most patients point to certain factors that provoke migraine attacks: emotional stress, dietary factors (ripe cheese, chocolate, alcohol), physical stimuli (bright or flickering light, smell, cigarette smoke, car exhaust fumes, changes in atmospheric pressure), changes in hormonal profile (menstruation, pregnancy, oral contraceptives), lack of sleep or too much sleep, irregular meal times, administration of certain drugs (nitroglycerin, reserpine).

Differential diagnosis includes tension-type headache (TTH) and cluster headache (see below for a description of their diagnostic criteria).

Migraine headaches with typical aura

The main diagnostic criteria for migraine with aura:

1. The patient must have had at least two migraine attacks.
2. The aura must have at least three of the following characteristics:
   • complete reversibility and indication of focal cerebral (cortical or brainstem) dysfunction with gradual (more than 4 min) onset and gradual development;
   • aura duration less than 60 minutes;
   • headaches begin after the aura at any time interval within 60 minutes (they can also occur before the aura or simultaneously with it).
3. The neurological status is normal, and the examination does not reveal an organic disease that could cause headache.

Provoking factors and differential diagnosis are the same as for migraine without aura.

The most common variant of a typical aura is visual disturbances (flashing zigzags, dots, balls, flashes, visual field disturbances), but not transient blindness.

A rare exception is migraine with a prolonged aura (more than 1 hour but less than a week); in this case, CT or MRI does not reveal focal brain damage. As a rule, such attacks are noted against the background of migraine attacks with a typical aura.

Hemiplegic migraine headaches

Hemiplegic and/or aphasic migraine occurs in the form of familial and non-familial variants and is manifested by episodes of hemiparesis or hemiplegia (less often - paresis of the face and arm). The motor defect increases slowly and spreads in a "march" pattern. In most cases, motor symptoms are accompanied by homolateral sensory disorders, especially in the cheiro-oral localization, also spreading in a "march" pattern. Rarely, hemiparesis can alternate from one side of the body to the other even within a single attack. Myoclonic twitching is possible (rare). Visual disorders in the form of hemianopsia or typical visual aura are typical. If aphasia develops, it is more often motor than sensory. These neurological symptoms last from several minutes to 1 hour, after which severe pulsating headaches develop, affecting half or the entire head. Headaches are accompanied by nausea, vomiting, photophobia or phonophobia. In some cases, the aura may persist throughout the headache phase. Unusual manifestations of severe hemiplegic migraine have been described, including fever, drowsiness, confusion, and coma, which may last from several days to several weeks.

Familial forms may be associated with retinitis pigmentosa, sensorineural hearing loss, tremor, and oculomotor disturbances (these neurological signs are permanent and have no relation to migraine attacks). Hemiplegic migraine has been described as a component of other hereditary diseases (MELAS, CADASIL {CADASIL - Cerebral Autosomal Dominant Arteriopathy with Subcortical Leucoencephalopathy}).

Complications of hemiplegic migraine, although rare, can be serious. Migraine-induced stroke occurs when the typical migraine aura with hemiparesis persists after a migraine attack, and neuroimaging reveals cerebral infarction that accounts for the observed neurologic deficits. Rarely, severe attacks of hemiplegic migraine can result in persistent neurologic microsymptoms that worsen with each attack to severe multifocal neurologic deficits and even dementia.

Differential diagnosis of hemiplegic migraine is carried out with ischemic stroke, transient ischemic attacks (especially when hemiplegic migraine occurs in old age), antiphospholipid syndrome, subarachnoid hemorrhage, as well as such forms as MELAS and CADASIL. Hemiplegic migraine has been described in systemic lupus erythematosus and in this case most likely represents a "symptomatic" migraine.

Basilar migraine headaches

The diagnostic criteria for basilar migraine are similar to the general diagnostic criteria for migraine with aura, but also include two or more of the following: visual symptoms in both temporal or nasal visual fields, dysarthria, dizziness, tinnitus, hearing loss, diplopia, ataxia, bilateral paresthesias, bilateral paresis, and decreased level of consciousness.

The disease begins in the second or third decade of life and can be combined with other forms of migraine. Women are affected three times more often than men. The provoking factors are the same as in other forms of migraine. In most cases, the aura lasts from 5 to 60 minutes, but sometimes it can last up to 3 days. Impaired consciousness may resemble sleep, from which the patient can be easily awakened by external stimuli; stupor and prolonged coma rarely develop. Other forms of impaired consciousness include amnesia and fainting. Drop attacks with short-term impaired consciousness are also described as a rare symptom. Epileptic seizures are possible following migraine aura. Headaches in almost all patients are occipital, pulsating ("beating") in nature, accompanied by nausea and vomiting. Unusual manifestations include one-sided pain or its localization in the anterior parts of the head. Photophobia and phonophobia are detected in about 30 - 50% of cases. As with other forms of migraine, aura symptoms without headache may also sometimes occur.

Differential diagnosis of basilar migraine is carried out with ischemic stroke in the basilar artery basin, posterior cerebral artery, transient ischemic attacks in the vertebrobasilar vascular basin. It is necessary to exclude antiphospholipid syndrome, hemorrhage in the brainstem, subarachnoid hemorrhage, arteriovenous malformation in the occipital cortex, sometimes meningoencephalitis, compression lesions of the brain in the craniocerebral junction and multiple sclerosis. Basilar migraine has also been described in CADASIL and MELAS syndromes.

Alice in Wonderland Syndrome

Alice in Wonderland syndrome is characterized by depersonalization, derealization (with distortion of ideas about space and time), visual illusions, pseudohallucinations, metamorphopsia. Presumably, this syndrome can be a migraine aura in rare cases and appears before, during, after an attack of cephalgia or without it.

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Migraine aura without headache

Migraine aura without headache (migraine equivalents of late life, acephalgic migraine) usually begins in adulthood and is more common in men. It manifests itself as transient visual ("fog", "waves", "tunnel vision", homonymous hemianopsia, micropsia, scotomas, "crown" phenomenon, complex visual hallucinations, etc.), sensory, motor or behavioral disturbances identical to the aura in classical migraine (migraine with aura), but without subsequent headache. The aura lasts 20-30 minutes.

Differential diagnosis requires careful exclusion of cerebral infarction, transient ischemic attacks, hypoglycemic episodes, temporal arteritis. This rare form is difficult to diagnose and is often a "diagnosis of exclusion".

The diagnosis is facilitated in the case of a change from acephalgic migraine to typical migraine attacks with aura.

Some authors distinguish migraine equivalents in childhood: cyclic vomiting of infants; alternating hemiplegia of infants; benign paroxysmal vertigo; dysphrenic migraine (affective disorders, behavioral disorders with aggression, sometimes headaches); Alice in Wonderland syndrome; abdominal migraine.

Among the variants of migraine with aura in children, in addition to those described in adults, the following are distinguished: acute confusional migraine (migraine with confusion), migraine stupor and transient global amnesia, abdominal migraine.

Differential diagnosis of migraine in children: migraine-like headaches in children have been described in diseases such as brain tumor, vascular malformations, hydrocephalus, pseudotumor cerebri, systemic inflammatory diseases such as lupus erythematosus, MELAS, complex partial epileptic seizures.

Ophthalmoplegic migraine headaches

Ophthalmoplegic migraine may begin at any age, but most commonly in infancy and childhood (under 12 years). It may occur as a single episode or, more typically, as repeated (sometimes weekly) attacks of ophthalmoplegia. Headaches are unilateral and occur on the side of the ophthalmoplegia. The side of the headache may sometimes alternate, but bilateral ophthalmoplegia is extremely rare. The headache phase may precede ophthalmoplegia by several days or begin simultaneously with the latter. Ophthalmoplegia is usually complete, but may be partial. Pupil involvement (mydriasis) is observed, but sometimes the pupil remains intact.

Diagnostic criteria:

1. There must be at least 2 typical attacks.
2. Headaches are accompanied by paresis of one or more oculomotor nerves (III, IV, VI cranial nerves).
3. Parasellar lesions were excluded.

Episodes of painless ophthalmoplegia in children as an acephalgic variant of migraine are described.

Differential diagnosis includes Tolosa-Hant syndrome, parasellar tumor, pituitary apoplexy. It is necessary to exclude Wegener's granulomatosis, orbital pseudotumor, diabetic neuropathy, glaucoma. In patients over 12 years of age, aneurysm must be excluded.

Retinal migraine headaches

Retinal migraine is characterized by decreased visual acuity, scotoma, concentric narrowing of the visual field, or blindness in one eye. Decreased vision may precede headache, or appear during a cephalgic attack, or after a headache. The diagnostic criteria are the same as for migraine with aura.

Differential diagnosis includes transient retinal circulatory disorder (amaurosis fugax), retinal artery or central retinal vein occlusion, ischemic optic neuropathy. It is necessary to exclude pseudotumor cerebri, temporal arteritis.

Headaches in complicated migraine

Complicated migraine manifests itself in two forms: migraine status and migraine cerebral infarction.

Migraine status is characterized by a series of severe migraine attacks that follow each other with an interval of less than 4 hours, or by one unusually long (more than 72 hours) and severe attack of severe headache. This condition is accompanied by repeated vomiting, severe weakness, adynamia, sometimes meningismus and mild stupor.

Migraine cerebral infarction (migraine stroke). Migraine attacks are sometimes accompanied by stroke. The diagnosis is based on the identification of a connection between a sudden onset of a migraine attack and the development of persistent neurological symptoms (not resolving within 7 days), as well as on the results of a neuroimaging study showing the development of a cerebral infarction. Such patients have a history of typical migraine, and a stroke develops during a typical migraine attack. The neurological status often reveals hemianopsia, hemiparesis or monoparesis, hemisensory disorders (with a tendency to cheiro-oral localization); ataxia and aphasia are observed less often. This complication can develop both with migraine with aura and with migraine without aura. Death has been described as a result of ischemia of the brain stem of migraine origin.

All other possible causes of stroke (rheumatic valvular disease, atrial fibrillation, cardiogenic cerebral embolism, vasculitis, arteriovenous malformation, etc.) and diseases that can mimic stroke must be excluded.

Cluster headaches

The following terms are used to describe cluster headache. An attack refers to a single headache attack; a cluster period refers to a period of time during which repeated attacks occur; remission refers to a period free of attacks; and a mini-cluster sometimes refers to a series of attacks that last less than 7 days.

Episodic and chronic cluster headaches are distinguished. In episodic cluster headaches, the cluster period lasts from 7 days to 1 year, and the remission period lasts more than 14 days; sometimes mini-clusters are observed.

In chronic cluster headaches, the cluster period lasts for more than a year without remissions or short remissions (less than 14 days) are observed. Each patient has their own circadian rhythm of attacks, cluster periods and remissions.

An attack is characterized by a rapid onset and rapid peak intensity (10-15 min) of headache, which lasts for about 30-45 minutes. The pain is almost always one-sided and has a drilling or burning, difficult to bear character. The most common localization is the orbital, retro-orbital, paraorbital and temporal region. The number of attacks per day is from one to three (varies from one per week to 8 or more per day). More than half of the attacks occur at night or in the morning. The pain is very severe, during an attack the patient usually cannot lie down, he prefers to sit, pressing with his hand on the sore spot or leaning his head against the wall, trying to find a position that relieves the pain. The attack is accompanied by parasympathetic activation in the pain zone: increased lacrimation, conjunctival injection, nasal congestion or rhinorrhea. Partial sympathetic paralysis is manifested by partial Horner's syndrome (slight ptosis and miosis). Hyperhidrosis in the facial area, pallor, sometimes bradycardia and other vegetative manifestations are observed.

Alcohol, nitroglycerin and histamine can trigger an attack during a cluster period.

Differential diagnosis includes migraine and trigeminal neuralgia. It is necessary to exclude such diseases as parasellar meningioma, pituitary adenoma, calcifying processes in the third ventricle, aneurysm of the anterior cerebral artery, nasopharyngeal carcinoma, ipsilateral hemispheric arteriovenous malformation and meningioma in the upper cervical spinal cord (symptomatic variants of cluster headache). The symptomatic nature of cluster pain may be indicated by: absence of typical periodicity, presence of "background" headache between attacks, other (in addition to Horner's syndrome) neurological signs.

Headaches in chronic paroxysmal hemicrania are a variant of cluster headache, which occurs predominantly in women. Attacks are usually shorter (5-10 minutes), but more frequent (up to 15-20 per day), occur almost daily and respond well to indomethacin (which is of great diagnostic importance).

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Psychogenic headaches

They can be observed in conversion disorders, hypochondriacal syndrome, depressions of various origins. In anxiety disorders, headaches are of the nature of tension headaches and are often provoked by stress factors. Conversion headaches are observed in the picture of polysyndromic demonstrative disorders and have a corresponding psycholinguistic correlate in the complaints and descriptions of the patient. Depression and affective disorders, as a rule, are accompanied by chronic, often generalized pain syndromes, including headaches.

In the diagnosis of these forms, the recognition of emotional-affective and personality disorders and ex juvantibus therapy on the one hand and the exclusion of somatic and neurological diseases on the other are of decisive importance.

Tension headaches

The most common type of headache. Headaches caused by overexertion are often accompanied by discomfort in the back, neck and shoulder muscles. The pain is often monotonous and pressing. Such headaches can be triggered by stressful situations, depression, and anxiety. To relieve pain, it is recommended to have a general relaxing massage session using aromatic oils, as well as acupressure.

There are episodic tension headaches (less than 15 days per month) and chronic tension headaches (more than 15 days per month with headaches). Both the first and the second can be combined with tension of the pericranial and neck muscles.

The pain is characterized by the absence of a clear localization, diffuse compressive character of the "helmet" type and is sometimes accompanied by soreness and increased tone of the pericranial muscles, which is revealed by their palpation and EMG examination. In the episodic form, headaches last from half an hour to 7-15 days, in the chronic form they can be almost constant. Tension headaches are accompanied by severe emotional disorders and vegetative dystonia syndrome. Nausea or vomiting are not typical, but anorexia may be present. Photophobia or phonophobia may be observed (but not their combination). Clinical and paraclinical examination does not reveal diseases that can cause headaches.

To diagnose a tension headache, there must be at least 10 episodes of this headache. Sometimes, episodic tension headaches can develop into chronic tension headaches. It is also possible to have a combination of tension headaches and migraines, as well as other types of headaches.

Differential diagnosis is carried out with migraine, temporal arteritis, volumetric processes, chronic subdural hematoma, benign intracranial hypertension. Sometimes glaucoma, sinusitis, temporomandibular joint disease require exclusion. In the above cases, neuroimaging methods, ophthalmoscopy, and cerebrospinal fluid examination are used.

Cervicogenic headaches

Cervicogenic headaches are typical for people of mature age and initially occur after a night's sleep or after lying down for a long time; later the pain may become constant, but in the morning hours it is more pronounced. Cervicogenic headaches are mainly associated with dysfunction in the joints, ligaments, muscles and tendons, mainly in the upper cervical segments of the spine. The pain is localized in the upper cervical region and the occipital region; when intensified, it takes the form of an attack, usually lasting several hours. In this case, it spreads to the parietal-temporal-frontal regions, where it manifests itself with maximum force. The pain is usually one-sided or asymmetrically expressed; it intensifies with movements in the cervical region or with palpation in this area. Nausea, vomiting and mild phono- and photophobia are possible during an attack; with straining or physical exertion at the height of the attack, severe pulsating pain is sometimes possible. Mobility limitations in the cervical spine, tension of individual muscles, painful muscle compactions are revealed. Anxiety and depression are often present; with a long course, a combination of cervicogenic headaches and TTH is possible in one patient.

Differential diagnosis is carried out with temporal arteritis, tension headache, migraine, space-occupying processes, Arnold-Chiari malformation, benign intracranial hypertension, overuse headaches (with a long course), space-occupying processes in the brain (tumor, abscess, subdural hematoma).

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Headaches in metabolic disorders

Diagnostic criteria:

1. There must be symptoms and signs of metabolic disorder;
2. The latter must be confirmed by laboratory tests;
3. The intensity and frequency of headaches correlates with fluctuations in the severity of metabolic disorder;
4. Headaches disappear within 7 days after normalization of metabolism.

Headaches associated with hypoxia (high-altitude headache, hypoxic headaches associated with lung diseases, sleep apnea) have been studied quite well; headaches associated with hypercapnia, a combination of hypoxia and hypercapnia; headaches associated with dialysis. Headaches associated with other metabolic disorders (ischemic headaches associated with anemia, arterial hypotension, heart disease, etc.) have been studied less.

Headaches due to neuralgia

Trigeminal neuralgia is characterized by typical pains that are shooting in nature (the pains begin immediately with maximum intensity like an electric shock and end just as instantly), are characterized by an exceptionally high ("dagger") intensity, appear more often in the area of the second or third branches of the trigeminal nerve, are characterized by the presence of trigger ("trigger") points, are provoked by touching these points, as well as by eating, talking, facial movements and negative emotions. Pain attacks are stereotypical, usually lasting from a few seconds to 2 minutes. No neurological symptoms are detected during examination.

The most common form of trigeminal neuralgia is the "idiopathic" form, which has recently been classified as tunnel-compression lesions of the V pair. When diagnosing, symptomatic forms of trigeminal neuralgia (with compression of the root or Gasserian ganglion; with central lesions - cerebrovascular accidents in the brainstem, intracerebral and extracerebral tumors, aneurysms and other volumetric processes, demyelination), as well as other forms of facial pain must be excluded.

Separate forms are herpetic neuralgia and chronic postherpetic neuralgia of the trigeminal nerve. These forms are a complication of herpetic ganglionitis of the Gasserian node and are recognized by characteristic skin manifestations on the face. Ophthalmic heroes zoster (lesion of the first branch of the trigeminal nerve) is especially unpleasant if the rash affects the cornea of the eye. If the pain does not subside after 6 months from the acute onset of herpetic lesions, then we can talk about chronic postherpetic neuralgia.

Glossopharyngeal neuralgia is characterized by typical shooting pains in the area of the tongue root, pharynx, palatine tonsils, less often - on the lateral surface of the neck, behind the angle of the lower jaw, Trigger zones are also detected here. The pain is always one-sided, can be accompanied by vegetative symptoms: dry mouth, hypersalivation and sometimes - lipothymic or typical syncopal states. Attacks are provoked by talking, swallowing, yawning, laughing, head movements. Mostly elderly women suffer

The idiopathic form of glossopharyngeal neuralgia is more common. Patients need examination to exclude symptomatic forms (tumors, infiltrates, and other processes).

Neuralgia of the intermediate nerve (nervus intermedius) is usually associated with a herpetic lesion of the geniculate ganglion of the intermediate nerve (Hunt's neuralgia). The disease manifests itself as pain in the ear and parotid region and characteristic rashes in the depth of the ear canal or in the oral cavity near the entrance to the Eustachian tube. Since the intermediate nerve passes at the base of the brain between the facial and auditory nerves, paresis of the facial muscles may develop, as well as the appearance of auditory and vestibular disorders.

Tolosa-Hunt syndrome (pain ophthalmoplegia syndrome) develops with a non-specific inflammatory process in the walls of the cavernous sinus and in the membranes of the intracavernous part of the carotid artery. It manifests itself as constant boring pain of peri- and retro-obituary localization, damage to the III, IV and VI cranial nerves on one side, spontaneous remissions and relapses at intervals of months and years, the absence of symptoms of involvement of nervous system formations outside the cavernous sinus. A good effect of corticosteroids is noted. Currently, the prescription of corticosteroids until the cause of this syndrome is determined is not recommended.

Recognition of Tolosa-Hunt syndrome is fraught with diagnostic errors. The diagnosis of Tolosa-Hunt syndrome should be a "diagnosis of exclusion."

Cervico-lingual syndrome develops with compression of the C2 root. The main clinical manifestations are pain in the neck, numbness and paresthesia in half of the tongue when turning the head. Causes: congenital anomalies of the upper spine, ankylosing spondylitis, spondylosis, etc.

Occipital neuralgia is characteristic of damage to the C2 root and the greater occipital nerve. There are periodic or constant numbness, paresthesia and pain (the latter are not obligatory; in this case, the term occipital neuropathy is preferable) and decreased sensitivity in the area of innervation of the greater occipital nerve (lateral part of the occipito-parietal region). The nerve may be sensitive to palpation and percussion.

Herpes zoster sometimes affects the ganglia on the C2-C3 roots. Other causes: whiplash injuries, rheumatoid arthritis, neurofibroma, cervical spondylosis, direct trauma or compression of the occipital nerve

Painful sensations are also possible in the picture of demyelinating damage to the optic nerve (retrobulbar neuritis), infarctions (microischemic lesions) of the cranial nerves (diabetic neuropathy).

Central post-stroke pain can sometimes be localized in the face, characterized by an unpleasant pulling and aching character. Its recognition is facilitated by the presence of similar sensations in the extremities (by hemitype). But a complex regional pain syndrome (reflex sympathetic dystrophy) with localization exclusively in the face has been described.

Pain syndromes in the picture of other lesions of the cranial nerves (cavernous sinus syndrome, superior orbital fissure syndrome, orbital apex syndrome, etc.).

Idiopathic stabbing headaches

Idiopathic stabbing pain is characterized by short, sharp, severe pain in the form of a single episode or short, recurring series. Headaches resemble a prick of a sharp piece of ice, nail, or needle and typically last from a few fractions of a second to 1-2 seconds. Idiopathic stabbing pain has the shortest duration of all known cephalgic syndromes. The frequency of attacks is very variable: from 1 time per year to 50 attacks per day, occurring at irregular intervals. The pain is localized in the distribution zone of the first branch of the trigeminal nerve (mainly the orbit, somewhat less often - the temple, parietal region). The pain is usually unilateral, but can also be bilateral.

Idiopathic stabbing pain can be observed as a primary affliction, but is more often combined with other types of headache (migraine, tension headaches, cluster headaches, temporal arteritis).

Differential diagnosis includes trigeminal neuralgia, SUNCT syndrome, chronic paroxysmal hemicrania, and cluster headache.

Chronic daily headaches

This term reflects a real clinical phenomenon and is intended to designate some variants of mixed cephalgic syndromes.

Chronic daily headache develops in patients already suffering from some primary form of cephalgia (most often migraine and/or chronic tension headache). As these primary diseases progress, a transformation of the clinical picture of migraine is sometimes observed ("transformed migraine"), under the influence of such "transforming" factors as depression, stress and abuse of analgesics. In addition, the picture is sometimes complicated by the addition of cervicogenic headaches. Thus, chronic daily headaches reflect various combinations of transformed migraine, tension headache, abuse and cervicogenic headaches.

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Hypnic headaches (Solomon's syndrome)

This unusual type of headache is seen mainly in people over 60. Sufferers wake up 1-3 times each night with a throbbing headache, sometimes accompanied by nausea. It occurs mainly at night, lasts about 30 minutes, and may coincide with the REM phase of sleep.

This syndrome differs from chronic cluster headache by the age of onset of the disease, generalized localization and the absence of characteristic vegetative symptoms. Such patients do not show any somatic or neurological abnormalities and the disease is benign.

Headaches in traumatic brain injury and post-concussion syndrome

Headaches in the acute period of traumatic brain injury do not actually require diagnostic interpretation. More difficult to assess are those headaches that appear after a mild ("minor") traumatic brain injury. They are associated with the development of post-concussion syndrome. The latter occurs in 80-100% of patients in the first month after a mild traumatic brain injury, but sometimes (10-15%) it can persist a year or more after the injury. If symptoms persist after 3 months and especially after 6 months, somatic complications or mental disorders must be excluded.

According to the international classification of headaches, post-traumatic headaches develop no later than 14 days after the injury. Acute post-traumatic cephalgia includes headaches that last up to 2 months; chronic post-traumatic headaches are pains that last more than 2 months. In general, post-traumatic headaches are characterized by a regressive course with a gradual improvement in well-being. A delayed headache that appears 3 months after a traumatic brain injury is most likely not associated with a traumatic brain injury.

Chronic post-concussion headaches resemble tension headaches in their clinical characteristics: they can be episodic or daily, often accompanied by tension of the pericranial muscles, localized on the side of the injury or (more often) diffuse. It is resistant to analgesics. At the same time, a couple of clinical studies (CT, MRI, SPECT or PET) do not reveal any deviations from the norm. Only psychological testing reveals emotional disorders and a characteristic set of complaints (anxiety, depressive, hypochondriacal and phobic disorders of varying severity or their combinations). There is a syndrome of vegetative dystonia, often rent installations and a closely related tendency to aggravation.

It is always necessary to exclude the possibility of chronic subdural hematoma (especially in the elderly), and additional trauma to the cervical spine, which is associated with the threat of cervicogenic headaches or other more serious complications. Due to the possible underestimation of the severity of the injury, such patients should be carefully examined using neuroimaging methods.

Headaches in infectious diseases

Headaches can be a concomitant symptom of flu, colds, acute respiratory viral infections. In such cases, the pain syndrome is eliminated with the help of painkillers containing paracetamol, ibuprofen, etc.

What forms do headaches have?

The abundance of causes and clinical forms of pain syndrome make rapid etiological identification difficult. Here are briefly outlined the main criteria for clinical diagnosis of headaches, based on their latest international classification.

1. Migraine headaches without aura.
2. Migraine headaches with aura:
   • hemiplegic migraine and/or aphasic;
   • basilar migraine;
   • Alice in Wonderland syndrome;
   • migraine aura without headache.
3. Ophthalmoplegic migraine.
4. Retinal migraine.
5. Complicated migraine:
   • migraine status;
   • migraine infarction.
6. Cluster headaches.
7. Chronic paroxysmal hemicrania (CPH).
8. Headaches associated with the impact of certain physical factors (physical activity, cough, coitus, external compression, cold headaches).
9. Headaches associated with hormonal fluctuations (cephalgia associated with pregnancy, menopause, menstruation, use of oral contraceptives).
10. Psychogenic headaches.
11. Tension headaches (TH).
12. Cervicogenic headaches.
13. Headaches associated with vascular diseases (arterial hypertension, arteriosclerosis, vasculitis).
14. Headaches in non-vascular intracranial diseases.
15. Headaches associated with medication use, including medication overuse headaches.
16. Headaches in metabolic disorders.
17. Headaches associated with diseases of the skull, eyes, ears, nose, lower jaw and other cranial structures.
18. Cranial neuralgia.
19. Idiopathic stabbing headaches.
20. Chronic daily headaches.
21. Hypnic headaches.
22. Headaches in traumatic brain injury and post-concussion syndrome.
23. Unclassifiable headaches.

Less common headaches

Headaches associated with exposure to certain physical factors (physical activity, cough, coitus, external compression, cold headache)

In most of the cases listed, patients either suffer from migraines or have a family history of them.

Benign headaches with physical exertion are provoked by physical activity, they are bilateral and pulsating and can acquire features of a migraine attack. Their duration varies from 5 minutes to a day. These headaches are prevented by avoiding physical activity. They are not associated with any systemic or intracranial disease.

However, it is useful to remember that headaches associated with many organic diseases (tumors, vascular malformations) can be intensified by physical exertion.

Benign cough headache is a bilateral, short-term (about 1 minute) headache that is provoked by coughing and associated with increased venous pressure.

Headaches associated with sexual activity develop during sexual intercourse or masturbation, increasing and reaching a peak of intensity at the moment of orgasm. The pain is bilateral, quite intense, but quickly passing.

Headaches manifest themselves in two ways: they can resemble either tension headaches or vascular headaches associated with a sharp rise in blood pressure. In differential diagnosis, it is necessary to remember that coitus can provoke subarachnoid hemorrhage. In some cases, it is necessary to exclude intracranial aneurysm.

Headache from external compression of the head is provoked by tight headgear, bandage or swimming goggles. It is localized at the site of compression and quickly passes when the provoking factor is eliminated.

Cold headache is provoked by cold weather, swimming in cold water, drinking cold water or eating cold food (most often ice cream). The pain is localized in the forehead, often along its midline, and is intense but quickly passing.

Headaches associated with hormonal fluctuations (pregnancy, menopause, menstruation, use of oral contraceptives)

Usually associated with fluctuations in blood estrogen levels in patients suffering from migraines.

Headaches associated exclusively with the menstrual period are almost always benign.

Headaches that begin during pregnancy can sometimes be associated with serious diseases such as eclampsia, pseudotumor cerebri, subarachnoid hemorrhage due to aneurysm or arteriovenous malformation, pituitary tumor, choriocarcinoma.

Headaches in the postpartum period are common and are usually associated with migraine. However, in the presence of fever, confusion and neurological symptoms (hemiparesis, seizures) or ocular edema, sinus thrombosis must be excluded.

Diagnostic tests for headaches

Diagnostic tests (the main method is a clinical interview and examination of the patient) for complaints of headaches:

1. Clinical and biochemical blood analysis
2. Urine analysis
3. ECG
4. Chest X-ray
5. Cerebrospinal fluid examination
6. CT or MRI of the brain and cervical spine
7. EEG
8. Fundus and visual field

The following may be required: consultation with a dentist, ophthalmologist, otolaryngologist, therapist, angiography, depression assessment, and other (as indicated) paraclinical studies.

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Headaches associated with medications, including medication overuse headaches

Some substances (carbon monoxide, alcohol, etc.) and drugs with a pronounced vasodilatory effect (nitroglycerin) can cause headaches. Long-term use of painkillers can become a factor that actively contributes to the chronicity of pain syndrome (the so-called abuse headaches).

Diagnostic criteria for medication overuse headache:

1. History of primary headache (migraine, tension headaches, long-term - more than 6 months post-traumatic headache).
2. Daily or almost daily headaches.
3. Daily (or every 2nd day) use of analgesics.
4. Ineffectiveness of drug and behavioral interventions in headache prevention.
5. A sharp deterioration in the condition if treatment is stopped.
6. Long-term improvement after discontinuation of analgesic drugs.

Headache can also be a manifestation of withdrawal (alcohol, drug addiction).

How are headaches treated?

Treatment of headaches primarily includes drug therapy using painkillers (analgin, dexalgin, paracetamol, ibuprofen). In some cases, light manual therapy techniques are used, as well as acupuncture, general strengthening and point massage is practiced. Depending on the specifics of the disease (for example, with migraine, hypotension, hypertension), the choice of drug is made by the therapist, based on the general clinical picture of the disease. The duration of treatment in each specific case is individual and can range from two weeks to one month.

How to prevent headaches?

To prevent headaches, it is recommended to spend time outdoors every day, do gymnastics, avoid stress and overexertion, you can use aromatic essential oils, applying one or two drops to the wrist, neck or temples. In case of individual intolerance to odors, the use of aromatherapy is contraindicated. A good way to prevent headaches is a daily massage, warming up the muscles of the back, neck, shoulders. Good rest and healthy sleep are also key to preventing headaches.

To prevent headaches, try to eat properly and in a balanced manner, preferably at the same time, get enough sleep, avoid stressful situations, do not forget about general strengthening daily exercises, and avoid alcohol and nicotine consumption.