Headache

Headaches throughout life repeatedly occur in almost every person. In most cases, they do not pose a serious danger and are a characteristic sign of overexertion or general overwork of the body. However, in a number of cases, headaches can indicate serious enough pathologies requiring qualified medical care.

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

Headaches associated with vascular diseases

Headaches often result from a decrease or increase in blood pressure. With lower arterial pressure, headaches are usually blunt, pressing, can be localized in the eye and nose, at the base of the neck. Sometimes they have a paroxysmal character, accompanied by a pulsation in the temporal region or in the region of the crown. The normalization of blood pressure in hypotension is facilitated by the use of caffeine (found in such drugs as citramone, pyramine, cofetamine, ascofen), as well as regular exposure to fresh air.

Increased blood pressure is often accompanied by a condition such as severe headaches, which can be accompanied by nasal bleeding and dizziness. The danger of this disease is that it significantly increases the risk of stroke. To treat high blood pressure, medications that are part of the group of diuretics, ACE inhibitors, angiotensin receptor blockers, beta-blockers are prescribed. The use of such drugs is possible only according to the doctor's prescription taking into account the individual characteristics of the organism, the etiology of the disease and age factors. With a sudden increase in pressure, it is necessary to take a pill of a diuretic, for example, triphas, furosemide. In the medicine cabinet it is also desirable to have pharmapidin (take no more than three or four drops inside) and captopril.

Arterial hypertension can cause a headache if:

• the diastolic pressure rises rapidly by more than 25% of the initial value; a constant level of diastolic blood pressure is 120 mm Hg;
• headaches occur against the background of acute hypertensive encephalopathy or if the rise in arterial pressure occurred against the background of eclampsia;
• these headaches are stopped by drugs that normalize the pressure.

Acute disorders of cerebral circulation (especially hemorrhagic strokes, subarachnoid hemorrhage) are accompanied by a headache, the duration of which is usually several weeks. The causes of these headaches usually do not cause doubt. In patients with a long history of stroke, headaches are usually due to other, in particular psychogenic factors. Often these patients underestimate the other possible forms of headache: migraine, tension headache, abusus and psychogenic (depressed) headaches.

Diagnostic criteria of temporal arteritis:

• age 50 years and older;
• the patient speaks of a new type of local headache;
• the intensity of the temporal artery and a decrease in its pulsation;
• lifting of ESR up to 50 mm per hour and above;
• an artery biopsy shows a necrotizing
• arteritis.

Headaches with vascular intracranial diseases

Tumors of the brain, as a rule, are accompanied by focal neurologic symptoms, signs of increased intracranial pressure, a corresponding picture in computer and magnetic resonance imaging.

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

Regardless of the nature of these diseases, three mandatory criteria are proposed for the diagnosis of such cephalgia:

1. In the clinical picture of the disease symptoms and signs of intracranial pathology should take place;
2. Paraclinical methods of examination show abnormalities confirming this pathology;
3. Headaches are assessed by the patient and the doctor as a new symptom (not typical of the patient before) or as a new type of headache (the patient says that the head began to hurt "differently", and the doctor observes the change in the character of the cephalgia).

Headaches associated with skull diseases

Diagnostic criteria:

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

Headaches with migraine

Such a disease, like a migraine, is accompanied by rather severe paroxysmal headaches. It is believed that this pathology has a connection with hereditary factors. To provoke a migraine attack and, accordingly, headaches, can last a long time in the sun, in a poorly ventilated room, insufficient duration of sleep and rest, the onset of menstruation in women, too sharp influence of irritating factors such as noise, bright light, as well as the state of emotion and mental overstrain. Headaches with migraine may be accompanied by the appearance before the eyes of luminous points, has a pulsating character, is localized more often in one part of the head, although it may extend to both halves. Severe headaches can persist for several hours, during the attack the patient is recommended to observe silence and rest. After the attack has passed, a person usually feels completely healthy. To stop the pain syndrome, drugs such as paracetamol, analgin, and aspirin can be used. Also in the complex therapy of migraine use the drug migrenol, sedalgin, metamizole, sumatriptan, vitamins, minerals, etc. The choice of medications for the treatment of migraine can be carried out only by a doctor on the basis of complete symptomatology of the disease and taking into account the individual characteristics of the organism.

Headaches with migraine without aura

The main diagnostic criteria for migraine without an aura:

1. The patient should have at least five episodes of headache lasting from 4 to 72 hours.
2. Headaches should have at least two of the following characteristics:
   • one-sided localization; pulsating character;
   • average or pronounced intensity (preventing the performance of the usual daily activities);
   • increased headache with normal physical activity or walking.
3. There must be at least one of the following symptoms during a headache:
   • nausea and / or vomiting; photophobia or phonophobia.
4. Neurological status without deviations from the norm, and the examination does not reveal an organic disease that can cause a headache.

Most patients indicate some of the factors that trigger migraine attacks: emotional stress, diet (mature cheese, chocolate, alcohol), physical stimuli (bright or flickering light, smell, cigarette smoke, automobile exhaust, changes in atmospheric pressure), changes in the hormonal profile (menstruation, pregnancy, oral contraceptives), lack of sleep or its excess, irregular intake of food, the administration of certain drugs (nitroglycerin, reserpine).

Differential diagnosis is performed with tension headache (HDN) and cluster headache (see below for a description of their diagnostic criteria).

Headaches with migraine with a typical aura

The main diagnostic criteria for migraine with aura:

1. The patient must have at least two migraine attacks.
2. Aura should have at least three of the following characteristics:
   • complete reversibility and indication of focal cerebral (cortical or stem) dysfunction with gradual (more than 4 min) onset and gradual development;
   • the duration of the aura is less than 60 minutes;
   • headaches begin after the aura through any time interval within 60 minutes (they can also occur before or simultaneously with the aura).
3. Neurological status without deviations from the norm, and the examination does not reveal an organic disease that can cause a headache.

The provoking factors and the differential diagnosis are the same as with migraine without an aura.

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

A rare exception is a migraine with a long aura (more than 1 hour, but less than a week); with CT or MRI not detecting focal brain lesions. As a rule, such seizures are noted against a background of migraine attacks with a typical aura.

Headaches with hemiplegic migraine

Hemiplegic and (or) aphathic migraine occurs in the form of a family and non-family variant and is manifested by episodes of hemiparesis or hemiplegia (less often - face and hand paresis). The motor defect grows slowly and spreads like a "march". In most cases, the motor symptoms are accompanied by homolateral sensory disorders, especially heyro-oral localization, which also spread as a "march". Rarely hemiparesis can alternate from one side of the body to another even within the same attack. Myoclonic jerking is possible (rarely). Typical visual disorders in the form of hemianopsia or a typical visual aura. If aphasia develops, then it is more often motor than sensory. These neurological symptoms last from a few minutes to 1 hour, after which severe pulsating headaches develop that capture half or all of the head. Headaches are accompanied by nausea, vomiting, photophobia or phonophobia. In some cases, the aura can persist throughout the entire phase of the headache. Described such unusual manifestations of severe hemiplegic migraine as fever, drowsiness, confusion and coma, which can last from several days to several weeks.

Family forms can be combined with pigment retinitis, sensorineural hearing loss, tremor and oculomotor disorders (these neurological signs are permanent and have no relation to migraine attacks). Hemiplegic migraine is described as an integral part of other hereditary diseases (MELAS, CADASIL - Cerebral Autosomal Dominant Arteriopathy with Subcortical Leucoencephalopathy).

Complications of hemiplegic migraine, although rare, but can be quite serious. A stroke induced by migraine occurs when a typical migraine aura with hemiparesis persists after a migraine attack, and neurovisualization reveals a cerebral infarction explaining the observed neurological deficit. In rare cases, severe attacks of hemiplegic migraine can lead to persistent neurological microsymptomatics, which increases with each attack to a coarse multifocal neurological deficit and even dementia.

Differential diagnosis of hemiplegic migraine is carried out with ischemic stroke, transient ischemic attacks (especially when hemiplegic migraine develops later), antiphospholipid syndrome, subarachnoid hemorrhage, and also forms such as MELAS and TSADASIL. Hemiplegic migraine is described in systemic lupus erythematosus and represents, in this case, most likely a "symptomatic" migraine.

Headaches with basilar migraine

Diagnostic criteria for basilar migraine are similar to the general criteria for the diagnosis of migraine with aura, but also include two or more of the symptoms listed below: visual symptoms in both temporal or nasal fields, dysarthria, dizziness, ringing in the ears, hearing loss, doubling, ataxia, bilateral paresthesia, 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 sick three times more often than men. The provoking factors are the same as with other forms of migraine. In most cases, the aura lasts from 5 to 60 minutes, but sometimes it can last up to 3 days. Disturbances of consciousness can resemble a dream, from which the patient can easily be induced by external stimuli; rarely stupor develops and prolonged coma. Other forms of impairment include amnesia and fainting. Drop-attacks with short-term impairment of consciousness are also described as a rare symptom. Possible epileptic seizures, following the migraine aura. Headaches in almost all patients have occipital localization, pulsating ("beating") character, accompanied by nausea and vomiting. Unusual manifestations are one-sided nature of pain or its localization in the anterior parts of the head. Photophobia and phonophobia are found in about 30-50% of cases. As with other forms of migraine, there may also sometimes be symptoms of aura without a headache.

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

Alisa's syndrome in Wonderland

Alisa's syndrome in Wonderland is characterized by the phenomena of depersonalization, derealization (with a distortion of ideas about space and time), visual illusions, pseudo-hallucinations, metamorphopsies. Presumably, this syndrome can be a migraine aura in rare cases and appears before, during, after an attack of cephalalgia or without it.

[5], [6]

Migraine aura without headache

A migraine aura without a headache (migraineous late-age equivalents, acephalic migraine) usually begins in adulthood and is more common in men. It is transient visual ("fog", "waves", "tunnel vision", homonymous hemianopsia, micropsy, scotoma, phenomenon of "crown", complex visual hallucinations, etc.), sensory, motor or behavior disorders, identical to aura in classical migraine migraine with aura), but without a subsequent headache. The duration of the aura is 20-30 minutes.

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

The diagnosis is facilitated in case of a change of acephalic migraine with typical migraine attacks with aura.

Some authors distinguish migraine equivalents of childhood: cyclic vomiting of infants; alternating hemiplegia of infants; benign paroxysmal dizziness; Dysphrenic migraine (affective disorders, behavioral disorders with aggressiveness, sometimes - headaches); syndrome "Alice in Wonderland"; abdominal migraine.

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

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

Headaches with ophthalmoplegic migraine

Ophthalmoplegic migraine can begin at any age, but most often in infancy and childhood (younger than 12 years). It can take the form of a single episode or, more typically, repeated (sometimes weekly) attacks of ophthalmoplegia. Headaches are unilateral and are observed on the side of ophthalmoplegia. The side of the headache can sometimes alternate, but bilateral ophthalmoplegia is extremely rare. The phase of the headache may precede ophthalmoplegia within a few days or begin together last. Ophthalmoplegia is usually complete, but it can also be partial. The involvement of the pupil (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 are excluded.

The episodes of painless ophthalmoplegia in children as an atsefalgic variant of migraine are described.

Differential diagnosis is performed with Tolosa-Hant syndrome (Tolosa-Hant), parasellar tumor, pituitary apoplexy. It is necessary to exclude Wegener's granulomatosis, orbital pseudotumor, diabetic neuropathy, glaucoma. Patients over 12 years of age should be excluded from aneurysm.

Headaches with retinal migraine

Retinal migraine is manifested by a decrease in visual acuity, scotoma, concentric narrowing of the field of vision or blindness in one eye. Reducing vision may be preceded by a headache, or appears during a cephalalgic attack, or after a headache. Diagnostic criteria are the same as for a migraine with an aura.

Differential diagnosis is performed with a transient impairment of blood circulation in the retina (amaurosis fugax), occlusion of the retinal artery or central vein of the retina, ischemic optic neuropathy. It is necessary to exclude pseudotumor cerebri, temporal arteritis.

Headaches with a complicated migraine

Complicated migraine manifests itself in two forms: migraine status and migraine infarction of the brain.

Migraine status is characterized by a series of severe, sequential migraine attacks with an interval of less than 4 hours, or one unusually long (more than 72 hours) and a severe attack of severe headache. This condition is accompanied by repeated vomiting, severe weakness, adynamy, sometimes - meningism and slight stunning.

Migraine infarction of the brain (migraine stroke). Migraine attacks are sometimes accompanied by a stroke. The diagnosis is based on revealing the connection between the sudden onset of migraine attack and the appearance of persistent neurologic symptoms (not occurring for 7 days), as well as the results of a neuroimaging study showing the development of a cerebral infarction. In such patients, a typical migraine appears in the anamnesis, and a stroke develops during a typical migraine attack. Neurological status often reveals hemianopsia, hemiparesis or monoparesis, hemisensory disorders (with a tendency to heyro-oral localization); Ataxia and aphasia are less common. This complication can develop both with migraine with aura, and with migraine without an aura. Death is described as a result of cerebral ischemia of the brain stem of migraine origin.

All other possible causes of stroke (rheumatic heart valves, atrial fibrillation, cardiogenic cerebral embolism, vasculitis, arteriovenous malformation, etc.) and diseases capable of mimicking a stroke should be excluded.

Beam headaches

When describing the headache, the following terms are used. By the term "attack" is meant a separate attack of a headache; the word "beam period" (or "cluster period") denotes the period of time during which repeated attacks are observed; "Remission" means a period free from attacks; "Mini-bundle" sometimes denote a series of attacks, which lasts less than 7 days.

Isolate episodic and chronic headache. With episodic bundle headache, the beam period lasts from 7 days to 1 year, and the period of remission is more than 14 days; mini-beams are sometimes observed.

With chronic headache, the cluster period proceeds without remission for more than a year or there are short remissions (less than 14 days). Each patient has its own circadian rhythmicity of attacks, cluster periods and remissions.

The attack is characterized by a rapid onset and a rapid peak in intensity (10-15 min) of headache, which lasts approximately 30-45 minutes. The pain is almost always one-sided and carries a drilling or burning, hardly tolerable, character. The most frequent localization: orbital, retro-orbital, paraorbital and temporal region. The number of attacks a day - from one to three (variations 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 strong, during the attack the patient usually can not lie, he prefers to sit, pressing his hand on the sore spot or leaning his head against the wall, trying to find a pose that alleviates the pain. Attack is accompanied by parasympathetic activation in the area of pain: increased lacrimation, conjunctiva injection, nasal congestion or rhinorrhea. Partial sympathetic paralysis is manifested by the partial Horner syndrome (small ptosis and miosis). There is hyperhidrosis in the face, pallor, sometimes bradycardia and other vegetative manifestations.

Alcohol, nitroglycerin and histamine can provoke an attack during the cluster period.

Differential diagnosis is carried out with migraine, trigeminal neuralgia. It is necessary to exclude such diseases as parasellar meningioma, pituitary adenoma, calculating processes in the area of the third ventricle, anterior cerebral artery aneurysm, nasopharyngeal carcinoma, ipsilateral hemispheric arteriovenous malformation and meningioma in the region of the upper cervical spinal cord (symptomatic beams of headache). The symptomatic nature of bundle pain can be said: the lack of typical periodicity, the presence of a "background" headache between attacks, and other (in addition to Horner's syndrome) neurological signs.

Headaches in chronic paroxysmal hemicrania relate to the variant of the bundle head hemorrhage, which occurs mainly 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 has important diagnostic significance).

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

Psychogenic headaches

Can be observed in conversion disorders, hypochondriac syndrome, depression of different origin. With anxiety disorders, headaches are characterized as headaches of tension 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 headache.

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

Tension headaches

The most common type of headaches. Headaches caused by overexertion are often accompanied by uncomfortable sensations in the region of the dorsal, cervical and brachial muscles. The pain is often monotonous, pressing. Such headaches can be triggered by stressful situations, depression, a sense of anxiety. To relieve the pain, it is recommended to have a general relaxing massage with aromatic oils, as well as acupressure.

Isolate 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 second can be combined with the tension of the pericranial muscles and muscles of the neck.

Pain is characterized by a lack of a clear localization, a diffusive compressive character such as a "helmet" or "helmet" and is sometimes accompanied by pain and an increase in the tone of the pericranial muscles, which is revealed by their palpation and EMG examination. With an episodic form, headaches last from half an hour to 7-15 days, with a chronic form they can be almost constant. Tension headaches are accompanied by severe emotional disorders and a syndrome of vegetative dystonia. Nausea or vomiting is not typical, but there may be anorexia. There may be photophobia or phonophobia (but not their combination). Clinical and paraclinical examination does not reveal diseases that can cause a headache.

To diagnose a tension headache, there must be at least 10 episodes of this headache. Sometimes an episodic tension headache can go into a chronic tension headache. Perhaps also a combination of tension and migraine headaches, as well as other types of headache.

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

Cervicogenic headaches

Cervicogenic headaches are characteristic of people of mature age and first arise after a night's sleep or after a prolonged lying; Later the pain can become permanent, but in the morning it is more pronounced. Cervicogenous headaches are mainly associated with dysfunction in the joints, ligaments, muscles and tendons mainly of the upper cervical segments of the spine. The pain is localized in the upper cervical region and the occipital region; when amplified, it takes the form of an attack, usually lasting several hours. In this case, it extends to the parietal-temporomandibular divisions, where it manifests itself with maximum force. Pain, as a rule, is one-sided or asymmetrically pronounced; it increases with movement in the cervical region or during palpation in this zone. At the time of an attack, nausea, vomiting and mild phonopathy and photophobia are possible, with severe straining or physical exertion at the height of the attack, severe pulsating pain is sometimes possible. The limitations of mobility in the cervical spine, tension of individual muscles, painful muscular densities are revealed. Often there is anxiety and depression; with a long course of possible combination of cervicogenic headaches and HDN in one patient.

Differential diagnosis is performed with temporal arteritis, tension headache, migraine, volumetric processes, malformations of Arnold-Chiari, benign intracranial hypertension, abyssal headaches (with prolonged course), volumetric processes in the brain (tumor, abscess, subdural hematoma).

[11], [12]

Headaches in metabolic disorders

Diagnostic criteria:

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

Headaches with hypoxia (altitude headache, hypoxic headaches with lung diseases, with sleep apnea) are quite well studied; headache with hypercapnia, a combination of hypoxia and hypercapnia; headaches during dialysis. Less studied headaches in other metabolic disorders (ischemic headaches with anemia, arterial hypotension, heart disease, etc.).

Headaches due to neuralgia

Neuralgia of the trigeminal nerve manifests as typical pain that is of a shooting character (pain begins immediately with maximum intensity as an electric shock and also ends immediately), differ in exceptionally high ("dagger") intensity, appear more often in the zone of the second or third branch of the trigeminal nerve, characterized by the presence of trigger points ("hack"), provoked by touching these points, as well as food, conversation, facial movements and negative emotions. Painful attacks are stereotyped, lasting usually from a few seconds to 2 minutes. During the examination, neurologic symptoms are not detected.

Most often there is an "idiopathic" form of neuralgia of the trigeminal nerve, recently it relates to tunneling-compression lesions of the V pair. Diagnosis should avoid the symptomatic forms of neuralgia of the trigeminal nerve (with compression of the spine or gasser node, with central lesions - cerebral circulation disorders in the brainstem, intracerebral and extra-cerebral tumors, aneurysms and other volumetric processes, demyelination), as well as other forms of facial pain .

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

Neuralgia of the glossopharyngeal nerve is characterized by typical shooting pains in the root of the tongue, pharynx, palatine tonsils, less often on the lateral surface of the neck, behind the angle of the lower jaw. Pain is always one-sided, can be accompanied by vegetative symptoms: dry mouth, hypersalivation and sometimes - lipotymic or typical syncopal conditions. Attacks are provoked by talking, swallowing, yawning, laughing, head movements. The predominantly elderly women

More common is the idiopathic form of the neuralgia of the glossopharyngeal nerve. Patients need a checkup to exclude symptomatic forms (tumors, infiltrates, etc. Processes).

Neuralgia of the intervening nerve (nervus intermedius) is usually associated with a herpetic lesion of the cranial node of the intervening nerve (Hant's neuralgia). The disease is manifested by pain in the ear and parotid region and characteristic eruptions in the depth of the auditory canal or in the oral cavity near the entrance to the Eustachian tube. Since the intermediate nerve on the base of the brain passes between the facial and auditory nerves, it is possible to develop paresis of facial muscles, as well as the appearance of auditory and vestibular disorders.

The Tolosa-Hunt syndrome (painful ophthalmoplegia syndrome) develops with a nonspecific inflammatory process in the walls of the cavernous sinus and in the envelopes of the intracavernous part of the carotid artery. It manifests itself as a constant boring pain of peri-and retro-localized localization, III, IV and VI cranial nerve damage, on the one hand, spontaneous remissions and relapses at intervals of months and years, and no symptoms of involvement of the neural system beyond the cavernous sinus. There is a good effect of corticosteroids. Currently, the appointment of corticosteroids before finding out the cause of this syndrome is not recommended.

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

Cervical-lingual syndrome develops with C2 spine compression. The main clinical manifestations: 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 typical for the defeat of C2 spine and a large occipital nerve. Periodic or permanent numbness, paresthesias and pains are identified (the latter are not necessary, in this case, the term occipital neuropathy is preferable) and a decrease in sensitivity in the innervation zone of the large occipital nerve (lateral part of the occipital parietal region). The nerve can be sensitive to palpation and percussion.

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

Pain sensations are also possible in the picture of demyelinating lesion of the optic nerve (retrobulbar neuritis), infarcts (micro-ischemic lesions) of the cranial nerves (diabetic neuropathy).

Central post-stroke pain can sometimes be localized in the face, characterized by an unpleasant pulling and breaking character. Her recognition is facilitated by the presence of similar sensations in the limbs (on the hemitis). But a complex regional pain syndrome (reflex sympathetic dystrophy) with localization exclusively in the face is described.

Pain syndromes in the picture of other lesions of the cranial nerves (cavernous sinus syndrome, upper globular cavity syndrome, orbital vertex syndrome, etc.).

Idiopathic stitching headaches

Idiopathic stabbing pain (stabbing) is manifested by a short acute severe pain in the form of a single episode or short repetitive series. Headaches resemble a prick with a sharp ice, nail or needle and in typical cases lasts from a few fractions of a second to 1-2 seconds. Idiopathic stitching pain has the shortest duration among all known tsefalgicheskih syndromes. The frequency of seizures is very variable: about 1 time per year to 50 attacks per day, appearing at irregular intervals. The pain is localized in the zone of distribution of the I branch of the trigeminal nerve (mainly the orbit, somewhat less often - the temple, parietal region). The pain is usually one-sided, but it can also be bilateral.

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

Differential diagnosis is performed with neuralgia of the trigeminal nerve, SUNCT - syndrome, chronic paroxysmal hemicrania, cluster headache.

Chronic daily headaches

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

Chronic daily headache develops in patients already suffering from any primary form of cephalgia (most often this is migraine and / or chronic tension headache). As these primary diseases progress, sometimes a transformation of the clinical picture of migraine ("transformed migraine") is observed, 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, and abusic and cervicogenic headaches.

[13], [14], [15], [16]

Hypnotic headaches (Solomon's syndrome "Solomon")

This unusual type of headaches is observed mainly in people older than 60 years. Patients wake up 1-3 times every night with a throbbing headache, which is sometimes accompanied by nausea. It appears mainly at night, lasts about 30 minutes and can coincide with the phase of fast sleep.

This syndrome differs from chronic headache with the age of onset of the disease, generalized localizations and the absence of characteristic vegetative symptoms. These patients do not show any somatic and neurological abnormalities and the disease is benign.

Headaches with traumatic brain injury and post-co-syndrome

Headaches in the acute period of craniocerebral trauma actually do not need a diagnostic interpretation. More difficult to assess are those headaches that appear after a minor ("minor") craniocerebral trauma. They are associated with the development of post-co-morbidity syndrome. The latter occurs in 80-100% of patients in the first month after a light craniocerebral trauma, but sometimes (10-15%) it can persist after a year or more after trauma. If symptoms persist after 3 months, and especially after 6 months, it is necessary to exclude somatic complications, or disorders in the mental sphere.

According to the international classification of headaches, post-traumatic headaches develop no later than 14 days after injury. To acute posttraumatic cephalalgia include headaches that last for up to 2 months; chronic posttraumatic headaches are pain lasting more than 2 months. In general, post-traumatic headaches are characterized by a regressive course with a gradual improvement in well-being. The delayed headache, which appeared after 3 months after the traumatic brain injury, is most likely not associated with craniocerebral trauma.

Chronic post-mortem headaches, in terms of their clinical characteristics, resemble a tension headache: they can be episodic or daily, often accompanied by pericranial muscle tension, localized on the side of the injury or (more often) are diffuse. It is resistant to analgesics. In this case, a couple of clinical studies (CT, MRI, SPECT or PET) do not reveal any abnormalities. Only psychological testing reveals emotional disorders and a characteristic set of complaints (anxious, depressive, hypochondriacal and phobic disorders of varying severity or combinations thereof). There is a syndrome of vegetative dystonia, often rental facilities and closely related to them the tendency to agrivate.

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

Headaches for infectious diseases

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

What forms have headaches?

The abundance of causes and clinical forms of pain makes it difficult to quickly etiologic identification. Here, the main criteria for the clinical diagnosis of headaches are summarized, based on their latest international classification.

1. Headaches with migraine without aura.
2. Headaches with migraine with aura:
   • hemiplegic migraine and (or) aphatic;
   • basilar migraine;
   • Alice's syndrome in Wonderland;
   • migraine aura without a headache.
3. Ophthalmoplegic migraine.
4. Retinal migraine.
5. Complicated migraine:
   • migraine status;
   • migraine infarction.
6. Beam headaches.
7. Chronic paroxysmal hemicrania (CPG).
8. Headaches associated with exposure to certain physical factors (physical activity, coughing, 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 (HDN).
12. Cervicogenic headaches.
13. Headaches associated with vascular diseases (arterial hypertension, arteriosclerosis, vasculitis).
14. Headaches with vascular intracranial diseases.
15. Headaches associated with taking medications, including abusus.
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 stitching headaches.
20. Chronic daily headaches.
21. Hypnotic headaches.
22. Headaches with craniocerebral trauma and post-co-syndrome.
23. Unclassified headaches.

Less common headaches

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

In most of these cases, patients either suffer from migraine, or mark it in a family history.

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

However, it is useful to remember that headaches in many organic diseases (tumors, vascular malformations) can be intensified under the influence of physical stress.

Benign cough headache is a bilateral short-term (about 1 minute) headache, which is provoked by a cough and is associated with an increase in venous pressure.

Headaches associated with sexual activity develop during sexual intercourse or masturbation, increasing and reaching a peak intensity at the time of orgasm. The pain is two-sided rather intense, but quickly passing character.

Headaches are manifested in two ways: they can resemble either a tension headache, or vascular headaches associated with a sharp rise in blood pressure. With a differential diagnosis, it must be remembered that coitus can provoke a subarachnoid hemorrhage. In some cases, it is necessary to exclude an intracranial aneurysm.

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

A cold headache is provoked by cold weather, swimming in cold water, drinking cold water or food (most often ice cream). The pain is localized in the forehead, often along its middle line, is intense, but rapidly passing.

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

Usually associated with fluctuations in the level of estrogens in the blood in patients with migraine.

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

Headaches that started during pregnancy can sometimes be associated with serious diseases such as eclampsia, pseudotumor cerebri, subarachnoid hemorrhage on the background of an aneurysm or arteriovenous malformation, a pituitary tumor, a choriocarcinoma.

Headaches in the postpartum period are often found and are usually associated with migraine headaches. However, in the presence of fever, stunning and neurological symptoms (hemiparesis, seizures) or edema on the fundus, sinus thrombosis should be excluded.

Diagnosis of headaches

Diagnostic studies (the main method is clinical examination and examination of the patient) with complaints about headaches:

1. Clinical and biochemical blood test
2. Analysis of urine
3. ECG
4. Chest x-ray
5. Investigation of CSF
6. CT or MRI of the brain and cervical spine
7. EEG
8. Ocular fundus and field of view

You may need: consultation of a dentist, ophthalmologist, otolaryngologist, therapist, angiography, depression assessment, and other (according to indications) paraclinical studies.

[17], [18], [19]

Headaches associated with taking medications, including abusus

Some substances (carbon monoxide, alcohol, etc.) and drugs with a pronounced vasodilator effect (nitroglycerin) can cause a headache. Long-term use of anesthetics can be a factor that actively contributes to the chronic pain syndrome (so-called abusus headaches).

Diagnostic criteria for abusic headache:

1. Presence of a primary headache in the anamnesis (migraine, tension headaches, prolonged - 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 drugs in the prevention of headaches.
5. Sharp deterioration in the event of discontinuation of treatment.
6. Long-term improvement after the abolition of analgesic drugs.

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

How are headaches treated?

Treatment of headaches, first of all, includes medical therapy with the use of analgesics (analgin, dexalgin, paracetamol, ibuprofen). In some cases, light techniques of manual therapy, as well as acupuncture, are practiced, and general and tonic massage is practiced. Depending on the specificity of the disease (for example, with migraine, hypotension, hypertension), the choice of a drug is made by the therapist, based on the overall clinical picture of the disease. Duration of treatment in each case is individual and can range from two weeks to one month.

How to prevent headaches?

For the prevention of headaches, it is recommended to go outdoors daily, exercise, avoid stress and overstrain, you can use aromatic essential oils, applying one or two drops to the area of the wrist, neck or temples. With individual intolerance of odors, the use of aromatherapy is contraindicated. A good way to prevent headaches is daily massage, warming up the muscles of the back, neck, shoulders. A full rest and a healthy sleep are also a key factor in the prevention of headaches.

To prevent headaches, try to eat right and balanced, preferably at the same time, allocate sufficient time for sleep, avoid stressful situations, do not forget about the general strengthening of daily exercise, exclude the consumption of alcohol and nicotine.