- Through a focused history and physical examination, be able to efficiently
differentiate between common benign headaches and the uncommon ominous headache
that warrrants additional work-up.
- Be able to explain to the patient your understanding of the source of
the headache in words that the patient can understand and that is reassuring
to the patient.
- Be able to offer the patient appropriate treatment and empathy, taking
into consideration the medication cost and effect on the patient's life.
Most are benign.
Greatest concern is over headaches that are persistent, severe, or sudden
- The physician's most immediate task is to identify, on clinical grounds,
the occasional patient who requires an aggressive work-up.
Intracranial sources of pain referred to the head:
circle of Willis blood vessels
medium-size arteries and major branches
Extracranial sources of headache:
skin, scalp, fascia, muscles
mucosal linings of the sinuses
Major mechanisms of headaches:
traction on pain-sensitive structures
inflammation of vessels and meninges
excessive muscle contraction
Acute headaches are those that appear suddenly, often without prior history.
Causes: cellulitis of the scalp, sinusitis, arteritis, severe muscle spasm,
acute distension of an aneurysm, subarachnoid bleeding, meningitis, encephalitis.
Acute and acute-recurrent headaches
Recurring headaches may be due to a chronic cause, such as emotional
depression and tension, or may be the result of a migraine process.
- classic migraine - positive family history; unilateral pain beginning as
a dull ache and developing into a pulsitile pain; often begins with a prodromal
loss of vision, flashing lights, or other neurologic symptoms, including weakness
or numbness of contralateral extremities; within an hour the pain intensifies
and is accompanied by nausea and vomiting; flare-up during periods of stress
- common migraine (sick headache) - usually starts upon awakening; unilateral;
increases over several hours; may be precipitated by hypoglycemia, ingestion
of alcohol or foods containing tyramine, nitrates or phenylephedrine; nausea,
vomiting, polyuria, diarrhea, chills and exhaustion often follow may persist
until the patient is able to get to sleep, may recur daily upon awakening
for several days.
- cerebral angiomas, vascular anomalies, and aneurysms - sudden onset of pain
and increase in intensity that peaks within minutes and is usually located
on the side of the vascular lesions; neurologic disturbances appear after
the pain subsides and outlast it; bruit may be heard over the anomaly; occur
more sporadically than migraines and are never relieved by ergot preparations.
cluster headaches - vascular headaches that occur in a series of 3 or more
severe headaches in a period of several days; may recur on a seasonal basis;
often occur on weekends after letdown of pressure; may be preceded by a
burning discomfort in the temple or eye, followed by a steady or throbbing
pain; often associated with ipsilateral conjunctival vascular congestion
and lacrimation, salivation, and blockage of nasal passages; pain on the
side of the forehead may spread bilaterally and be accompanied by a deep
pain in the neck; use of alcohol, nitrates, nicotine or other vasodilators
may trigger an attack.
In patients with headache of a more prolonged time course, it is important
to note any changes in the quality and severity of the pain and in the
appearance of associated neurologic signs.
Subacute and chronic forms of headache
- brain tumors - headache usually an indolent discomfort with intermittent
exacerbations, often precipitated by changes in position, coughing or straining;
may be a new complaint; initially localized; not relieved by relaxation; may
worsen when patient is lying down; neurologic signs appear as brain tissue
is further affected by an enlarging neoplasm or increasing cerebral edema;
headache may also be a late symptom.
- muscle contraction headaches - common in chronically tense, anxious or
depressed people; patients complain of a constant sensation around the head;
claim to have the headache all the time ("I get up with it and go to bed with
it."); severe pain develops, with radiation along muscles spreading across
ligamentous attachments and insertions; common site overlooked is temporomandibular
joints; persistent cramping of muscles may induce ischemia, thus resulting
in a localized throbbing sensation.
- oral contraceptives - longterm use can produce constant, dull headache
in susceptible women; especially true in those who are migraine-prone.
Good listening skills, with sufficient time and patience.
An analysis of the quality, location, and temporal profile will usually
suggest an etiologic explanation.
check for muscle tension
palpation of scalp
auscultation of head
good ENT exam
good neuro exam
Laboratory evaluation - does not replace a good history and physical; may
skull, chest, and cervical x-rays
CBC, U/A, Sed rate, FBS
- Ergot derivatives are the most effective, but must be administered in
the prodromal period or at least immediately after the onset of the headache.
Oral use is desirable unless nausea and vomiting are present, then suppositories
may be used. Note these are contraindicated in the presence of peripheral
vascular disease, angina pectoris, impaired hepatic or renal function, or
improvement in restful sleep
Barbiturates and other sedatives have a limited but useful role.
Tranquilizers and antidepressants reduct the frequency of headaches in
Dilantin works as a prophylactic measure in a small number of patients.
Methylsergide reduces the frequency and severity of many with common migraines
or cluster headaches.
Propranolol is effective in reducing cluster headaches in some patients.
Amitriptyline is useful in reducing the frequency and severity of vascular
headaches in many cases.
Muscle contraction and tension headaches
- Reassuring explanation of the nature of the headache is often quite helpful.
- It is necessary for the physician to break the cycle of anxiety and depression
leading to headache and to identify the underlying psychological conflicts
and precipitating emotional events. Symptoms may be ameliorated with antidepressant
or antianxiety drugs.
- A combination of analgesics, muscle relaxants, and sedatives has been
found useful if administered soon after the onset of the headache.
- Correction of malocclusion of the teeth, if this is a problem.
- Heat, prolonged soaks, including immersion of the neck and back of head,
along with massage and relaxation techniques.
D.L. Powell, MD