Headache

1. 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.
2. 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.
3. Be able to offer the patient appropriate treatment and empathy, taking into consideration the medication cost and effect on the patient's life.

• Common complaint.
• Most are benign.
• Greatest concern is over headaches that are persistent, severe, or sudden in onset.
• 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
• large veins
• dura
• meninges

• Extracranial sources of headache:
• skin, scalp, fascia, muscles
• mucosal linings of the sinuses
• arteries
• temporomandibular joints
• teeth

• Major mechanisms of headaches:
• traction on pain-sensitive structures
• inflammation of vessels and meninges
• vascular dilitation
• excessive muscle contraction

• 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 is common.

• 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.

• 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.

• Physical examination.
• blood pressure
• ophthalmologic exam
• 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 include:
• skull, chest, and cervical x-rays
• CBC, U/A, Sed rate, FBS
• EEG
• lumbar puncture
• CT

• Migraines
• 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 pregnancy.
• adequate relaxation
• improvement in restful sleep
• stress reduction
• Barbiturates and other sedatives have a limited but useful role.
• Tranquilizers and antidepressants reduct the frequency of headaches in certain patients.
• 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.

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D.L. Powell, MD
updated 6/22/04