Primary headaches

Primary headaches include clinically heterogeneous types of headaches. The pathogenesis of these remains not fully understood, and therapeutic approaches have not yet been substantiated by controlled clinical trials. In most cases, the forms are primary (benign). At the same time, the symptoms of some of them may resemble clinical manifestations in secondary cephalalgia, when it is mandatory to perform additional, including neuroimaging, studies. For example, "4.6. Primary thunderhead headache "is almost always characterized by a sharp onset, so patients often go to emergency departments. For differential diagnosis with organic causes of cephalosys, a thorough examination is necessary.

4. Other primary headaches (ICGS-2, 2004)

• 4.1. Primary stitching headache.
• 4.2. Primary cough headache.
• 4.3. Primary headache with physical exertion.
• 4.4. Primary headache associated with sexual activity.
  • 4.4.1. Preorganizmic headache.
  • 4.4.2. An orgasmic headache.
• 4.5. Hypnical headache.
• 4.6. Primary thunderhead headache.
• 4.7. Hemikraniya continua (hemicrania continua).
• 4.8. New daily (initially) persistent headache.

[1], [2], [3]

Primary stitching headache (4.1)

Synonyms are ice-pick headache, jabs and jolts syndrome, periodic ophthalmia.

Description

Transient, clearly localized painful punctures in the head region that occur suddenly in the absence of an organic pathology of the underlying structures or cranial nerves.

Diagnostic criteria

• A. Pain that occurs as a sensation of a single injection (puncture) or a series of pricks in the head area that meets the BD criteria.
• B. The pain is localized exclusively or predominantly in the innervation zone of the first branch of the trigeminal nerve (in the eye, temple or crown area).
• C. Stitching pain lasts a few seconds and is repeated throughout the day at an irregular frequency from one injection to several series of injections.
• D. Pain is not accompanied by concomitant symptoms.
• E. Not related to other causes (abnormalities).

In a single published descriptive study, 80% of the injections had a duration of 3 seconds or less. In rare cases, patients repeated multiple stitching pains for several days. A single episode of the status of primary piercing cephalgia, which lasted for 1 week, was described. The injections can move from one area of the head to the other within one half of the head or go to the other side. If stitching pains occur strictly in one area of the head, it is necessary to exclude structural damage of this area and in the zone of innervation of the corresponding nerve. Stitching pains most often occur in patients with migraine (about 40%) or headache (about 30%), and, as a rule, in the areas of the head, where migraine or cluster headache is usually localized.

Treatment

In several uncontrolled studies, the positive effect of indomethacin was noted; Other studies have not confirmed its effectiveness in this form of headache.

Primary cough headache (4.2)

Synonyms

Benign cough headache, headache of the Valsalva phenomenon.

Description

Headache provoked by coughing or tension (straining) in the absence of intracranial pathology.

Diagnostic criteria

• A. Headache meeting criteria B and C.
• B. Sudden onset, duration of pain from 1 s to 30 min.
• C. Pain occurs only in connection with coughing, stress (straining) or with a Valsalva test.
• D. Not related to other causes (violations).

Primary cough headache is usually bilateral and more common in people older than 40 years. Indomethacin, as a rule, has a positive effect, but there have been several cases of an answer to indomethacin and with symptomatic coughing cephalgia.

In 40% of cases, cough headache is symptomatic (secondary), and in most patients Arnold-Chiari type I malformation is detected. Other cases of symptomatic cough pain may be due to vertebrobasilar disorders or intracranial aneurysm. Of great importance for the differential diagnosis of symptomatic cough cephalges and primary cough headache are neurovisualizing methods of investigation.

[4], [5],

Primary headache with physical stress (4.3)

Description

Headache, provoked by any physical stress. Various subtypes are noted, for example, the headache of movers.

Diagnostic criteria

• A. Pulsating headache that meets criteria B and C.
• B. Duration of pain from 5 minutes to 48 hours.
• C. Pain occurs only during or after a physical stress.
• D. Not related to other causes (violations).

Primary headache with physical exertion often occurs in hot weather or at altitude. Cases of this pain relief after ingestion of ergotamine are described. In most cases, indomethacin is also effective. At the first appearance of cephalgia associated with physical stress, it is necessary to exclude subarachnoid hemorrhage or stratification of the artery.

[6], [7]

Primary headache associated with sexual activity (4.4)

Synonym

Coital headache.

Description

Headache, provoked by sexual activity, with no intracranial disorder. Usually begins as a dull bilateral pain, increases with sexual arousal and reaches a maximum during orgasm.

There are two forms of coital cephalgia:

• preorganizmic (4.4.1) - dull pain in the head or neck, combined with a feeling of tension in the neck and / or chewing muscles, occurs during sexual activity and grows together with sexual arousal;
• orgasmic (4.4.2) - a sudden intense ("explosive") headache that occurs during orgasm.

Data on the duration of cephalalgia associated with sexual activity are not uniform. It is believed that its duration can vary from 1 min to 3 h. The appearance of postural cephalgia after sexual intercourse is described. In this case, the headache resembles pain at low CSF pressure, it should be regarded as "7.2.3. Headache associated with spontaneous (idiopathic) lowering of liquor pressure. " Approximately 50% of cases describe a combination of primary cephalalgia associated with sexual activity, primary headache with physical stress and migraine. At the first appearance of orgasmic pain, it is necessary to exclude subarachnoid hemorrhage or stratification of the artery.

Treatment

In most cases, because of the short-term nature of treatment is not carried out. If the headache associated with sexual activity lasts more than 3 hours, it is necessary to examine the patient to determine the nature of the pain.

Hypnical headache (4.5)

Synonyms

"Alarm" headache.

Description

Attacks of a dull headache, always awakening the patient from sleep.

Diagnostic criteria

• A. A dull headache that meets the BD criteria.
• B. Pain develops only during sleep and awakens the patient.
• C. At least two of the following:
  • Occurs> 15 times a month;
  • lasts for> 15 min after waking up;
  • first appears after 50 years.
• D. It is not accompanied by vegetative symptoms, it is possible that one of the following symptoms is present: nausea, photo or phonophobia.
• E. Not related to other causes (abnormalities).

Pain in hypnotic cephalalgia is more often bilateral, usually of mild or moderate intensity. Severe pain is noted in 20% of patients. Attacks last for 15-180 minutes, sometimes a little longer. At the first appearance of hypnotic cephalalgia, it is necessary to exclude intracranial pathology, as well as to conduct differential diagnostics with trigeminal vegetative cephalalgia.

Treatment

Several patients were effective in the use of caffeine and lithium preparations.

Primary thunderhead headache (4.6)

Description

Intensive, acutely arose cephalgia, resembling pain in the rupture of an aneurysm.

Diagnostic criteria

• A. An intense headache that meets criteria B and C.
• B. Both of the following characteristics:
  • a sudden onset with a maximum intensity of less than 1 minute;
  • duration of pain from 1 hour to 10 days.
• C. Does not repeat regularly over the next weeks or months.
• D. Not related to other causes (violations).

There is still insufficient evidence that thunderous cephalgia is a primary disorder. The diagnosis of primary thunderous cephalgia can be established by observing all the diagnostic criteria and the normal results of neuroimaging studies and lumbar puncture. Therefore, a thorough examination aimed at eliminating other causes of pain is absolutely necessary. Thrombotic cephalgia is often combined with intracranial vascular disorders, in particular with subarachnoid hemorrhage. In connection with this, additional examination should be aimed primarily at excluding subarachnoid hemorrhage, as well as such disorders as cerebral venous thrombosis, unexploded vascular malformation (more often aneurysm), stratification of arteries (intra- and extracranial), CNS angiotensis, reversible benign angiopathy of the central nervous system and apoplexy of the pituitary gland. Among other organic causes of a thunderous headache are colloid cyst III of the ventricle, a decrease in cerebrospinal fluid pressure and acute sinusitis (in particular, with barotrauma injuries). Symptoms of thunderhead headache are also a manifestation of other primary forms: primary cough headache, primary cephalalgia with physical stress and primary headache associated with sexual activity. The encoding "4.6. Primary thunderhead headache "can only be used after all the organic causes of pain have been ruled out.

Treatment

There is evidence of the effectiveness of gabapentin in the primary form of thrombosed cephalgia.

Hemikraniya continua (Hemicrania continua) (4.7)

Description

Persistent, severely unilateral headache, facilitated by taking indomethacin.

Diagnostic criteria

• A. Headache lasting more than 3 months, meeting the criteria of BD.
• B. All of the listed characteristics:
  • unilateral pain without side change;
  • daily prolonged pain without light gaps;
  • moderate intensity with episodes of pain intensification.
• C. During an exacerbation (pain) on her side, at least one of the following vegetative symptoms occurs:
  • Injection of conjunctiva and / or lacrimation;
  • nasal congestion and / or rhinorrhea;
  • ptosis and / or miosis.
• D. The effectiveness of therapeutic doses of indomethacin.
• E. Not related to other causes (abnormalities).

Hemikraniya continuum, as a rule, proceeds without remissions, however, rare cases with a remitting course are described. Differential diagnosis must be made with chronic tension headache, chronic migraine and chronic form of bundle headache. A distinctive feature is the effectiveness of indomethacin.

Treatment

Indomethacin in most cases has a beneficial effect.

New daily (initially) persistent headache (4.8)

Description

Daily headache, from the outset, flowing without remission (the chronicle occurs no later than 3 days after the onset of pain). Pain, as a rule, is bilateral, pressing or compressive in nature, of light or moderate intensity. Possible photo, phonophobia or mild nausea.

Diagnostic criteria

• A. Headache lasting more than 3 months, meeting the criteria B and B.
• B. Occurs daily, from the very beginning there is no remission or chronization occurs no later than 3 days after the onset of pain.
• C. At least two of the following characteristics of pain:
  • two-sided localization;
  • Pressing / compressive (non-pulsating) character;
  • light or moderate intensity;
  • It does not increase due to usual physical activity (for example, walking, climbing stairs).
• D. Both symptoms of the following:
  • no more than one of the following symptoms: photo, phonophobia or mild nausea;
  • absence of moderate or severe nausea and vomiting.
• E. Not related to other causes (abnormalities).

A new, persistent headache can occur from the beginning without remission or very quickly (within a maximum of 3 days) to acquire a continuous character. Such a beginning of pain is well remembered, usually patients clearly describe it. The ability of the patient to accurately recall how the pain began, its initially chronic character - the most important criteria for diagnosing a new daily persistent headache. If the patient is having difficulty in characterizing the initial period of pain, a diagnosis of "chronic tension headache" should be established. Unlike the new daily persistent headache that occurs in people who have not previously complained of cephalalgia, with chronic tension headaches, there is an indication in the history of typical episodes of episodic tension headache.

Symptoms of a new daily persistent headache may also be reminiscent of some secondary forms of cephalgia, such as headache with lowering of liquor pressure, posttraumatic cephalalgia and headache caused by infectious lesions (in particular, viral infections). To exclude such secondary forms, additional research is needed.

Treatment

A new daily persistent headache can have two outcomes. In the first case, cephalgia may end spontaneously after several weeks without treatment, in the second case (refractory type of flow) even intensive treatment (traditional for chronic tension headache and chronic migraine) can be useless and the pain permanently remains chronic.