Headache Diagnosis and Symptoms

Headache Definition and Epidemiology

• Headache is defined as pain in the head, a common symptom in 93% of males and 99% of females.
• It is a symptom of a disease that requires further investigation.

History of Headache

• Every patient with headache requires a detailed history, including:
  • Duration of suffering from headache
  • Severity and pattern of headache (increasing, constant, or paroxysmal)
  • Side and site of headache
  • Duration of each attack
  • Precipitating factors (e.g., cough, psychic stress)
  • Relieving factors (e.g., vomiting, analgesics)
  • Character of headache
  • Associating symptoms
  • History of head trauma, nasal obstruction or discharge, visual disorders, teeth problems, etc.
  • Presence of anxiety, tension, or depression
  • Presence of signs of systemic disease (fever, anemia)

Mode of Production of Headache

• All tissues covering the cranium are pain sensitive (e.g., arteries, muscles, and pericranium)
• Skull bone itself is insensitive to pain
• Intracranial pain sensitive structures include:
  • Venous sinuses
  • Dura matter
  • Cerebral arteries

Classification of Headache

• Migraine
• Tension type headache
• Cluster headache
• Headache associated with vascular disorders
• Headache associated with head trauma
• Cranial neuralgia

Headache Referred from Diseases

• Skull bone
• Neck (e.g., cervical spondylosis)
• Eyes (e.g., glaucoma, refractive errors)
• Ears (e.g., otitis media, otitis externa)
• Nose and sinuses (e.g., sinusitis)
• Teeth, jaw, and related structure disorders
• Temporo-mandibular joint diseases

Migraine

• Common in females (15-20%) than males (5-10%)
• Strong family history is present
• Onset: at or shortly after puberty
• Frequency:
  • May occur 2-3 times/week
  • Frequency decreases with age
  • More frequent at time of menstruation
  • Less frequent during pregnancy
• Precipitating factors of migraine attacks:
  • Excitation or excessive work
  • Menses
  • Bright light
  • Extra sleep
  • Strong smells
  • Minor trauma
  • Certain diets (e.g., cheese, chocolate, alcohol, nuts)

Diagnostic Criteria of Migraine

• A. At least 5 attacks fulfilling B-D criteria
• B. Headache attacks lasting 7-48 hours
• C. Headache has at least two of the following:
  • Unilateral
  • Pulsating
  • Moderate/severe
  • Aggravated by walking or any routine physical stress
• D. During headache at least one of the following:
  • Nausea and/or vomiting

Management of Migraine

• I. General measures:
  • Avoidance of stressful situations
  • Mental and physical fatigue
  • Precipitating diet elements
• II. Medical measures:
  • During the attack:
    • Strong analgesics (e.g., aspirin, paracetamol)
    • Ergot preparation (e.g., Migranil) oral, IM, or suppository
    • 5HT-receptor agonist (Sumatriptan) given in 6mg SC injection
  • Prophylactic measures:
    • B-blockers (e.g., Inderal 30-120 mg/day)
    • Ca+ channel blockers
    • Tri-cyclic antidepressants
    • Antiepileptics (e.g., valproate and topiramate)

Tension Type Headache

• Frequently associated with anxiety, depressive disorders, and insomnia
• The commonest (68% of males and 88% of females)
• Each attack lasts from 30 minutes up to 7 days
• At least two of the following:
  • Pressing/tightening (non-pulsating) quality
  • Mild or moderate
  • Bilateral location
• No nausea or vomiting
• No phonophobia or photophobia
• May be associated with tender pericranial muscles
• Usually precipitated by stressful situations, associated with insomnia, and lost appetite

Treatment of Tension Type Headache

• Analgesics
• Muscle relaxants
• Antidepressants and anxiolytics