Causes of headache

Possible causes of headache:

• infectious diseases of the central nervous system - meningitis, brain abscess, arachnoiditis, encephalitis, malaria, typhus (Brill's disease);
• non-infectious diseases of the central nervous system - brain tumors, subarachnoid hemorrhage, increased intracranial pressure, temporal arteritis, angle-closure glaucoma, trigeminal neuralgia, poisoning with medicines or carbon monoxide, food poisoning;
• mental or psychological condition - neuroses, asthenic conditions after the transferred flu and other infectious diseases;
• other diseases, such as - arterial hypertension, anemia, thrombosis, sinusitis, middle ear diseases, bruise, trauma, etc.

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

In searching for the causes of the headache, in addition, you need to take into account the age of the patient.

Causes of chronic headache in different age groups

Children (from 3 to 16 years)	Adults (17 - 65 years old)	Elderly (over 65 years of age)
Migraine. Psychogenic pain. Pain of tension. Post-traumatic. Tumors (rarely, mainly the trunk of the brain and the posterior cranial fossa)	Tension headache. Migraine. Post-traumatic. Cluster headache. Tumors. Chronic subdural hematoma. Cervicogenic. Glaucoma	Cervicogenic headache. Cranial arteritis. Persistent tension headache. Persistent migraine. Rarely cluster headache. Tumors. Chronic subdural hematoma. Glaucoma. Paget's disease (deforming osteitis)

Headache can occur with a variety of intracranial or extracranial diseases. Their rapid diagnosis and adequate therapy are often critical. Treatment of the underlying disease, which is the cause of secondary headache, positively affects the headache itself. In general, the description of the treatment of secondary headaches is beyond the scope of this chapter. However, in some cases, the use of medicines may be required to control pain, if the therapy for the underlying disease has not eliminated it. In this situation, specific treatment recommendations can be given, depending on the clinical characteristics of the pain.

The following are some of the most common secondary headache options.

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

Post-traumatic headache

Chronic headache can occur after a closed or open brain injury, as well as after neurosurgical intervention. Severity of headache often does not correspond to the severity of the injury. By nature, posttraumatic headache most often resembles a primary tension headache. In a series of 48 patients with chronic post-traumatic headache, 75% experienced a headache that was qualified as a tension pain, 21% had almost no headache from migraine without an aura, and 4% had an "unclassifiable" headache. Quite often in this situation, there is a mixed character of the headache. Headache that occurs daily is usually described as a permanent non-pulsating pain that can be interrupted by severe migraine-like attacks and / or frequent brief episodes of acute, piercing pain. According to the classification of the International Headache Society, the headache regressed within 8 weeks after the injury is designated as acute, and retaining beyond this period is chronic.

Headache after trepanation of the skull is very variable and may include pain and soreness at the site of the surgical wound; a feeling of discomfort of a compressive or pressing nature, similar to a tension headache, or the pulsating pain characteristic of a migraine. Postoperative pain is usually not accompanied by nausea, vomiting or photophobia, however these migraine-like symptoms are sometimes found.

There are several approaches to the treatment of post-traumatic headache. Cognitive and behavioral methods - for example, biological feedback or relaxation techniques - often prove to be quite effective, "arming" patients with techniques that enable them to cope with chronic pain. There are only a few reports of clinical trials of drugs for post-traumatic headaches. In one uncontrolled study, it was noted that amitriptyline resulted in an improvement in 90% of patients. There are some reports of a positive effect of doexpene, nortriptyline, imipramine, selective serotonin reuptake inhibitors. A positive effect in post-traumatic headache may be provided by valproic acid or gabapentin as monotherapy or in combination with amitriptyline. These drugs are especially useful in the presence of post-traumatic epilepsy. Physical therapy is useful in the presence of persistent muscle spasms, and antidepressants - with concomitant depression and anxiety.

Infections - as a cause of headache

Headache can occur with various systemic and intracranial infections. It can accompany a common cold or be a threatening sign of a serious CNS infection that can be fatal, which makes it necessary to analyze the headache in the context of other symptoms. Below is a summary of the most important infectious causes of headache, treated with antibacterial agents and / or surgery.

Meningitis - an inflammation of the meninges - is caused by bacteria, viruses or fungi. Clinical manifestations of meningitis can develop after a short-term systemic disease or manifest without any previous episode. Characteristic symptoms of meningitis are intense headache, fever, neck pain, photophobia, rigidity of individual muscle groups. In addition, epileptic seizures, skin rashes, depression of consciousness are possible. Urgent examination should include lumbar puncture (in the absence of edema of optic discs). In the presence of focal symptoms (eg, unilateral paresis, oculomotor disorders, pupil changes, oppression of consciousness), CT should be performed immediately, preferably with contrast, to exclude swelling of the posterior cranial fossa, abscess or hematoma, in which lumbar puncture can be dangerous. Nevertheless, with suspicion of bacterial meningitis, the expectation of a neuroimaging study should not delay the appointment of antibiotic therapy or serve as an excuse to postpone a lumbar puncture for any length of time.

Meningoencephalitis suggests the presence of inflammation in both the membranes and the substance of the brain. Its cause may be a viral infection, as, for example, in herpetic meningoencephalitis. Meningoencephalitis often develops after a short-term influenza-like illness and can clinically resemble meningitis, although its onset is usually not so sudden. Epileptic seizures or changes in mental status may be several days ahead of other symptoms. When investigating the cerebrospinal fluid, an increase in the protein level and lymphocytic pleocytosis can be detected. The detection of temporal lobe damage in CT and MRI also supports this diagnosis.

Brain abscess is caused by a bacterial infection and is a focal cluster of inflamed molten necrotic tissues inside the brain. It can develop due to contact or hematogenous spread of the infection, and its pathogens are most often streptococci, staphylococci and anaerobes. Headache, vomiting, focal neurological symptoms and depression of consciousness arise as a result of compression of surrounding structures and brain edema.

Subdural empyema is the accumulation of pus between the parenchyma of the brain and the dura mater, manifested by headache, vomiting, oppression of consciousness, focal neurologic symptoms.

AIDS can cause a headache during the acute and chronic phases of HIV infection, as well as in connection with opportunistic infections accompanying it, for example, toxoplasmosis or cryptococcosis. The cause of the headache may also be the side effects of drugs used to treat both HIV infection (eg, zidovudine or lamivudine) and opportunistic infections (fluconazole, amphotericin B).

Acute sinusitis can cause pain in the forehead and face area. The presence of other signs, for example, shading of the sinuses during radiography or transillumination, fever, purulent discharge from the nose, is necessary to confirm the diagnosis and initiation of antibiotic therapy. Many people mistakenly believe that any pain in the frontal region necessarily indicates a sinusitis. Sinusitis of the main or maxillary sinuses can simulate a migraine.

Respiratory and systemic viral infections can cause mild to moderate headache. With these "small" infections, there is no rigidity of the neck muscles, photophobia or changes in consciousness.

Vascular diseases and headache

An intense headache can be a manifestation of the occlusion of the intracranial vessels or the leakage of blood through a weakened or damaged vascular wall. Blood, poured into the subarachnoid space, is a strong chemical irritant that can cause intense headache and stiff neck. Cerebral ischemia is also capable of causing headache. The cause of the headache may be the following vascular lesions.

Subarachnoid hemorrhage most often occurs as a result of blood seepage during the rupture of an aneurysm of the cerebral vessel and is a neurosurgical emergency. The diagnosis can be confirmed with CT or lumbar puncture. Aneurysm can be identified by angiography.

Below are the symptoms that allow suspected subarachnoid hemorrhage and requiring urgent examination with CT and / or lumbar puncture.

1. Sudden onset of pain, which reaches maximum intensity within a few seconds.
2. A significant intensity of pain, which the patient often describes as "the most powerful headache he has ever experienced in life."
3. Rigidity of cervical or occipital muscles as a result of their contraction.
4. Rapid suppression of the level of consciousness due to the compression of the trunk.
5. Other less specific signs include photophobia and vomiting.

The emergence of a detailed picture of subarachnoid hemorrhage may be preceded by episodes-precursors associated with a small leakage of blood and having a similar nature, but less intensity than the main episode. These anticipatory episodes require careful examination, since massive hemorrhage may occur in the near future (usually from 2 to 14 days). Small focal symptoms can also develop due to compression of neighboring structures with an increasing aneurysm.

Subdural hematoma is the accumulation of blood between the dura mater and the surface of the brain, often manifested by a monotonous persistent headache. Subdural hematoma can occur even after a slight head injury, but sometimes develops spontaneously, especially in elderly people and patients taking anticoagulants.

Hemorrhage in the cerebellum is a condition requiring urgent neurosurgical interventions and manifests itself as a headache in the occipital parts, followed by rapid development of signs of compression of the brain stem such as depression of consciousness, impaired innervation of the pupils, oculomotor disorders or paresis.

Arteriovenous malformations (AVM) are congenital vascular anomalies, in which blood, passing the capillaries, is discharged from the arteries into the venous structures. AVM can cause an ipsilateral headache, which in some cases is accompanied by visual and sensory symptoms resembling a migraine aura. Sometimes AVMs are identified by listening to noise over the area of the orbit or head. AVM can also cause hemorrhages, which leads to more intense headache and the appearance of focal neurological symptoms.

Occlusion of the intracerebral arteries with the development of a heart attack can sometimes be accompanied by a headache. Nevertheless, in the whole clinical picture of ischemic stroke is dominated by focal neurological symptoms, and not headache. Occlusion of cerebral venous sinus can also be associated with headache and focal neurological defect. Thrombosis of the cavernous sinus is manifested by intense pain in the eye and injection of the sclera, which is accompanied by the defeat of III, V ₁ V ₂ and VI cranial nerves. The sagittal sinus thrombosis can be manifested by headache, epileptic seizures and focal neurological symptoms.

Stratification of the carotid artery results from the fact that the blood separates the muscle layers of the vascular wall after injury to the intima. Carotid stratification can occur after an apparent slight injury to the head or neck (for example, after a sharp turn of the head of a taxi driver) and is manifested by intense pain in the head and neck, which can irradiate to the eyebrow, eye, orbital region or mastoid process. With the separation of the carotid artery, the following neurologic symptoms may occur:

1. paralysis of the tongue due to defeat of the XII nerve (probably due to mechanical compression of ansa cervicalis on the neck);
2. Horner's syndrome with the involvement of sympathetic fibers of the perivascular plexus.

Treatment can consist in the use of anticoagulants for 3 months, after which they switch to antiaggregants for the same period. Resection of a residual exfoliation aneurysm, a possible source of embolism, may be required if such an operation is technically possible.

Intracranial tumors - as the cause of headaches

Many patients believe that their headache is a manifestation of an unrecognized brain tumor. Fortunately, in the vast majority of cases, the headache is not associated with any structural changes. Nevertheless, intracranial tumors are important to be able to diagnose.

Of 111 patients with a brain tumor confirmed by CT or MPT, Forsyth and Posner (1992) reported chronic headache in 48% of cases. Pain caused by a tumor is usually monotonous and bifrontal, but often stronger on the ipsilateral side. In terms of its characteristics, this pain is more often close to a tension headache (77%) than to a migraine (9%), and is often intermittent and moderately intense (the average score on a 10-point scale is 7 points). The pain is accompanied by nausea about half of its duration. Headache, which occurs against the background of increased intracranial pressure, is usually resistant to traditional analgesics. "Classic" headache with brain tumors that occurs in the morning, was noted only in 17% of patients.

For brain tumors, there is no specific type of headache. Signs that allow suspected intracranial swelling include: edema of optic discs, the appearance of new neurologic symptoms, an extended episode of headache that first appeared after age 45, the presence of a previous oncological disease, increasing cognitive impairment or depression of consciousness.

Pain can regress after resection or radiation therapy of the tumor. If surgical intervention is planned in the near future, aspirin and other non-steroidal anti-inflammatory drugs should be avoided, as they increase the risk of bleeding. If surgical intervention is not possible, symptomatic therapy is necessary. With mild or moderate headache, conventional analgesics are effective, while with severe headache, narcotic analgesics may be required. Perifocal edema can be reduced with a corticosteroid (dexamethasone, 4 mg orally every 6 hours) or mannitol (200 ml of 20% solution intravenously every 8 hours), each of which can relieve the headache again.

Autoimmune and inflammatory diseases - as causes of headache

Temporal (giant cell) arteritis is a disease characterized by inflammatory lesions of the branches of the carotid arteries, primarily the temporal artery. Usually it affects people over 60 years of age and can lead to a rapid and irreversible loss of vision due to granulomatous lesion with occlusion of the posterior ciliary artery or central retinal artery. In favor of temporal arteritis,

1. pain in the orbital or frontotemporal region, which has a monotonous permanent character, sometimes with a sensation of pulsation;
2. increased pain under the influence of cold;
3. pain in the lower jaw or tongue, worse with chewing ("intermittent claudication" of the lower jaw);
4. additional common symptoms: weight loss, anemia, mononeuropathies, changes in liver function;
5. reduction in visual acuity, visual field defects with blanching or edema of optic discs and exfoliating retinal hemorrhage (with anterior ischemic optic nerve neuropathy) or blanching of the retina with the presence of a cherry red spot (in the occlusion of the central artery of the retina).

Timely adequate therapy is important, as transient visual impairment can quickly turn into irreversible blindness. If you suspect a temporal arteritis, you should immediately begin treatment with corticosteroids to avoid loss of vision, which in 75% of cases after a one-sided becomes bilateral. In 95% there is an increase in ESR. The diagnosis can be confirmed with a temporal artery biopsy, which should be done no later than 48 hours after the start of corticosteroid therapy.

With an increase in ESR, methylprednisolone is given, 500-1000 mg intravenously every 12 hours for 48 hours, after which they switch to prednisolone inwards at a dose of 80-100 mg per day for 14-21 days, followed by a gradual corticosteroid withdrawal for 12-24 months. The rate of cancellation is determined by the dynamics of ESR.

[5], [6], [7], [8], [9], [10]

Tholose-Hunt syndrome

Granulomatous process in the area of the cavernous sinus or upper glandular gap, manifested by painful ophthalmoplegia and decreased sensitivity in the forehead. Treatment consists of corticosteroid therapy.

Headache can be a manifestation of collagenoses, autoimmune angiopathies, such as isolated angiitis of the CNS. Headache usually decreases after the therapy of vasculitis, which is its cause.

Toxico-metabolic disorders

Headache caused by exogenous substances can occur due to direct exposure to certain substances or as a result of withdrawal symptoms in people who constantly take psychoactive substances.

Metabolic disorders

Headache can be a manifestation of various metabolic disorders. This group includes the following variants of the headache.

1. Headache with hypercapnia occurs with an increase in pC0 ₂ > 50 mm Hg. Art. In the absence of hypoxia.
2. Headache with hypoglycemia occurs when the blood sugar level falls below 2.2 mmol / l (<60 mg / dl).
3. A dialysis headache occurs during or shortly after a hemodialysis session (to reduce the headache, the speed of dialysis should be reduced).
4. Altitude headache usually occurs within 24 hours after a rapid ascent to a height of more than 3000 m. Headache in this case is accompanied by at least one other symptom of altitude sickness, including Cheyne-Stokes breathing at night, pronounced dyspnoea with physical exertion or desire take a deeper breath.
5. Headache caused by hypoxia is usually observed with low environmental pressure or pulmonary disease with a fall in P0 ₂ in the arterial blood below 70 mm Hg. Art.
6. Headache with sleep apnea is probably associated with hypoxia and hypercapnia.

Substances causing a headache

Substances directly cause headache pain

• Alcohol
• Amphotericin B
• Verapamil
• Danazol
• Diclofenac
• Dipyridamole
• Ivdometacin
• Cocaine (crack)
• Sodium mono-glutamate
• Nitrates / nitrites
• Nifedipine
• Ondansetron
• Ranitidine
• Reserpine
• Tyraamine
• Carbon monoxide
• Phenylethylamine
• Fluconazole
• Cimetidine
• Estrogens / oral contraceptives

Substances causing an abstinent headache

• Alcohol
• Barbiturates
• Caffeine
• Opioid analgesics
• Ergotamine

Eye diseases and headache

Headache can occur in patients with eye diseases, in particular - with two forms of glaucoma.

1. Pigmentary glaucoma is a form of open-angle glaucoma that occurs when the iris pigment is released into the fluid in the anterior chamber of the eye under physical exertion. As a result, the outflow of fluid through the trabecular system is blocked. This state of the cup occurs in young men suffering from myopia, and is manifested by headache and blurred vision, which are provoked by physical exertion.
2. Acute closed-angle glaucoma - characterized by blockade of free fluid flow through the pupil, which leads to a shift in the iris forward and obstruction of the trabecular system. It is manifested by dilated pupils with no response to light, blurred vision, intense pain in the eyeball, corneal opacity, and marked increase in intraocular pressure. Episodes are provoked by the expansion of the pupils under the influence of physiological or pharmacological factors.

For both types of glaucoma, the patient should be immediately referred to an ophthalmologist. In acute angle-closure glaucoma, laser iridotomy is often indicated. Glaucoma is sometimes confused with a cluster headache. However, with a cluster headache, the pupil narrows and does not expand, and in addition, ptosis is often observed.

[11], [12], [13]

Arterial hypertension as a cause of headache

A sharp increase in blood pressure (when the diastolic pressure exceeds 120 mm Hg) can cause a headache. Pain in hypertension is often diffuse and usually most pronounced in the morning, gradually weakening over the next few hours.

With the expressed arterial hypertensia four variants of a headache are connected.

1. Acute hypertensive reaction to exogenous substance. Headache occurs in a temporary connection with the rise in blood pressure under the influence of a specific toxin or drug and disappears within 24 hours after the normalization of blood pressure.
2. Preeclampsia and eclampsia. During pregnancy, childbirth and in the early postpartum period, headache may be accompanied by other manifestations of preeclampsia, including increased arterial pressure, proteinuria, edema. Headache usually regresses within 7 days after lowering blood pressure or allowing pregnancy.
3. Pheochromocytoma - adrenal tumor secreting norepinephrine or epinephrine, can cause a short-term headache, accompanied by sweating, anxiety, palpitations and a sharp rise in blood pressure.
4. Malignant hypertension, accompanied by acute hypertensive encephalopathy, causes headache, grade 3 or 4 retinopathy, and / or depression. In this case, there is a temporary link between the headache and the episode of pressure build-up; After lowering blood pressure, the pain disappears within 2 days.

[14], [15], [16], [17], [18], [19], [20]

Decrease and increase in intracranial pressure

Headache with intracranial hypotension is possible with a decrease in intracranial pressure (ICP) to 50-90 mm of water. Which is usually caused by a decrease in the volume of the cerebrospinal fluid and often causes a monotonous pulsating headache, sometimes quite intense. It is probably due to a decrease in the "cerebral cushion" and elasticity of the brain, which leads to the tightening of the shell and vascular structures that have pain receptors. Pain with intracranial hypotension increases in the vertical position and decreases in the horizontal. Headache can begin gradually or suddenly and is accompanied by dizziness, visual impairment, photophobia, nausea, vomiting, sweating. Although the headache with intracranial hypotension can begin spontaneously, most often it develops after lumbar puncture (LP). Other reasons for intracranial hypotension include intracranial surgery, ventricular shunting, trauma, various systemic disorders, for example, severe dehydration, condition after dialysis, diabetic coma, uremia, hyperventilation. With persistent headache, the presence of a cerebrospinal fluid should be avoided by radioisotope cisternography or CT myelography.

Postpunctional headache is caused by excessive leakage of cerebrospinal fluid through the hole in the dura mater made by a puncture needle. After lumbar puncture, headache occurs in 10-30% of cases, twice as often in women as in men. The headache can begin in a few minutes or a few days after the puncture and lasts from two days to two weeks. Treatment may include the use of corticosteroids, ingestion of additional amounts of fluid and salt, intravenous fluids, inhalation of CO _2, and the administration of methylxanthines, for example theophylline 300 mg 3 times a day, caffeine 500 mg IV, or endolumbal intro autoblood closure defect in the dura mater.

Headache with increased intracranial pressure (intracranial hypertension) is caused by deformation of dural and vascular structures that have pain sensitivity, or direct pressure on the cranial nerves that conduct painful impulses, for example, the trigeminal nerve. Although the localization of this variant of the headache is variable, most often the pain is bilateral and localized in the fronto-temporal region. The cause of increased ICP can be volumetric formations, cerebral spinal fluid circulation blockage, hemorrhages, acute hypertensive encephalopathy, venous sinus thrombosis, adrenal hyper or hypofunction, altitude sickness, tetracycline or vitamin A intoxication and many other conditions. In most cases, the cause of increased intracranial pressure and headache can be established. Treatment of the underlying disease usually leads to regression of the headache.

Idiopathic intracranial hypertension (pseudotumor cerebri) is a condition manifested by headache, edema of optic discs, transient episodes of blurred vision that occur in the absence of any change in cerebrospinal fluid, except for increased intracranial pressure. However, in one of the clinical series in 12 patients there was no edema of the optic discs. The condition is not associated with hydrocephalus or other identifiable causes. In women, idiopathic intracranial hypertension is found 8-10 times more often than in men. A typical patient is a woman of childbearing age with excess weight.

The diagnosis of idiopathic intracranial hypertension is confirmed by lumbar puncture data (CSF pressure> 250 mm Hg with normal CSF composition) and neuroimaging, which excludes the presence of volumetric formation or hydrocephalus. When examining the fields of vision, the blind spot is often expanded. Although there is a tendency for spontaneous recovery, measures to reduce intracranial pressure are usually necessary because of the threat of loss of vision. Sometimes often repeated LL are effective, but they are associated with a risk of complications, including post-puncture headache, brain dislocation, development of a spinal epidermoid tumor or infection. Pharmacotherapy is primarily aimed at reducing the production of cerebrospinal fluid and includes acetazolamide and furosemide. Furosemide, a potent loop diuretic, should be administered along with potassium preparations, and its ability to induce arterial hypotension should also be considered. Surgical treatment consists of fenestration of the optic nerve channels and ventriculoperitoneal shunting.

[21], [22], [23], [24], [25], [26]