HEADACHE

Prepared by :

Dr : Abdulrahman sallam
Associated Prof. of Neuropsychiatry

HEADACHE
Definition: It is discomfort of pain in the head (it is a symptom and not a disease)

Pain sensitive structures

A-Extracranial (arteries, muscle of cranium and pericranium)

All tissues covering the cranium (cranium after periostium inward

non sensitive) . B-Intracranial 1- Arteries (big ones at the base of the brain, cerebral and dural arteries)

2- Part of the dura which cover the base of the skull

3- Nerves carrying pain fibers 5th, 9th, 10th of cranial nerves and upper 3 cervical sensory roots .
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Mechanism of headache
1-Vascular: through vasodilatation and stretching of arteries and veins, thus stimulating pain fibers in their wall e.g. migraine.

2-Muscular: through spasm occipitofrontalis and neck muscles

e.g. psychogenic . 3-Pressure ,traction or distortion :of intracranial pain sensitive

structures e.g. S.O.L .

4-Inflamation of sensitive structure: e.g. meningitis, arteritis and neuritis .

5-Refferad pain : from structure within the head e.g. disease of eye,
nasal, ear sinus, and teeth also from thoraco-abdominal viscera e.g. constipation .
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Description of headache:
1- Tim sitting : continuous or intermittent and duration.
2- Distribution: local or generalized.

3- Character of pain: thropping, aching, stabbing ,

stretching and bursting (commonly organic) but sense of sever pressure, weight on the head, marked tightness, numbness or bizarre description (commonly psychogenic ).
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4- Severity: interference with the job of patient, sleep

and response to analgesic or not.

5- Aggravating factors : physical effort or mental strain. 6- Symptoms associated with headache: nausea, vomiting, visual disturbance, depression, anxiety, insomnia, difficulty in concentration and easy fatigability.

History:
History of head injury, Infection of ear sinuses,

mental exhaustion or psychogenic disorder and family

history of similar condition.

Examination:
Mental state, head inspection, fundoscopy, B.P, skull x-ray, EEG, CT-brain and brain MRI if necessary.
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Classification according to the cause

Symptomatic
local

Psychonic
General

Extracranial

Intracranial

1- Migraine 2- Reffered pain 3- Fibrositis 4- Neuritis and neuralgia 5- Temporal arteritis

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1- S.O.L 2- Post traumatic 3- Meningitis 4- Altered C.S.F

1- Hypertension 2- Infection 3-Toxication 4- Misllaneous

I- Psychogenic :
A-Etiology: Anxiety, depression and neurosis .

B-Mechanism:
1- spasm or tonic contraction of skeletal muscles

of the head and neck .

2-change in the tone of cranial vessels (vasoconstriction followed by rebound vasodilatation) .

C- Characters: continuous and long duration (weeks, months or even years) generalized non responsive to analgesic drugs , aggravated by psychogenic factors .

E- Examination:
no evidence of organic illness .

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II-Referred pain :
Etiology : e.g. Eye errors of refraction particularly hypermetropia which associated with prolonged contraction of frontalis , temporalis and nuchal muscle, teeth dental caries especially molar, sinusitis and otitis media.

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III-Fibrositis:
A- Etiology: Rheumatic of the scalp or the sub

occipital tissues .
B- Character: Continuous (days , weeks)

aching, shooting , stabbing in character aggravating by

head and neck movements , coughing and sneezing . Also associated with tenderness of affected region .

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IV-Neuritis and neuralgia

A-Interstitial neuritis Etiology: Inflammation of the connective tissue of peripheral nerve, neurotropic virus, septicemia

metabolic abnormality (e.g. diabetic) or repeated

trauma (pressure neuritis ) e.g. occipital headache due

to cervical spondylosis. Pain result firstly by

inflammatory exudates later by over growth of connective tissue .
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Character: Paroxysmal pain for several hours involved nerve distribution, hyperalgesia of area supplied by the nerve and the nerve trunk is tender on pressure, dull aching and shooting pain along the course of nerve, Sometimes severe until interference with sleep,

precipitated by cold exposure .

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B-Neuralgia:

It is characterizes by pain along the involved nerve with no apparent cause, and without impairment its function (neuritis lead to impairment of nerve function). Irregular bout and occurred at same time and same period for

along time start in the morning at 11 A.M to 4 P.M

e.g supraorbital neuralgia .
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V-Temporal arteritis
Etiology: It is regarded as immune complex disorder . Character: subacute onset with malaise and fever

continuous but worse at night corresponds to distribution

of affected vessels ,aggravated by strain, thickened,

tenderness nodules and diminish pulsation by palpation of

temporal artery, periarterial redness and swelling for 10 days but artery remain tender for along time, diplopia or unilateral blindness (affecting ophthalmic artery) also E.S.R is high.
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VI-Intracranial space occupying lesion

At first paroxysmal and later become permanent, at first it is localized and later it is diffuse and generalized Paroxysmal develop during lying down during sleep due to increase tension in the head . The patient may be awaked early in morning due to

headache and he may obtain some relief by sitting in the

bed .
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VII-Post-traumatic headache.
Etiology 1- Psychogenic due to symptoms of memory disturbance and irritability . 2- Organic due to meningeal adhesion, sensory nerve fibers injury, sustained contraction of skeletal muscle of head ,neck and distension blood vessels

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Character Paroxysmal, recurring for few months (3 - 4) maximal

at the site of injury and spread to variable extent, occur

spontaneously or a result of physical efforts, sharp, shooting or thropping in character .

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VIII- Meningeal headache

Etiology

Meningitis, subarachnoid hemorrhage lead to

displacement of blood vessel by exudates or blood and irritation of blood vessels . Character Continuous, worse at night, severe at occipital region, boring or shooting in character associated with neck rigidity and CSF change .
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IX- Headache due to C.S.F. pressure change

1- Increase pressure: due to stretch and displacement pain sensitive structure intracranial, improved by sitting . 2- Decrease pressure: due to traction on pain sensitive

structure

intracranial

improving

by

lying

down

throbbing in character .

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X- Hypertensive headache
Mechanism: stretching extra cranial vessels Character: intermittent, localized in occipital region and throbbing . when it is sever associated with vomiting .

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XI-Infection and toxication headache

Mechanism: vasodilatation and stretching intracranial vessels due to histamine release . Character: continuous, generalized or frontal

localization, throbbing and sense of fullness associated with

symptoms of infection and toxication .

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XII- Miscellaneous group of headache

1- Cough headache It is may be some sort of intracranial arteritis and coughing stretches the inflammed artery . 2- Visceral headache

Disease of the intra-thoracic and intra-abdominal viscera may

cause headache through the central connection between the sensory nucleus of the trigeminal and vagus nerve in the brain, by this way

pain from thoracic and abdominal viscera may be referred to the head .

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3- Headache due to constipation: the same mechanism as

before . 4- Headache due to Anaemia :due to increase the amplitude of pulsation . 5- Headache due to hypoglycemia : due to intracranial vasodilatation . 6- Allergic headache: due to oedema .

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XII-Migraine
Definition: It is a paroxysmal headache commonly hemicranial

preceded by aura .
Etiology and pathology :The condition is due to vascular change first vasoconstriction fallowed by vasodilatation .The aura is due to vasoconstriction of one branch of the internal carotid artery and headache occurs due to vasodilatation and stretching of the branch of

external carotid artery

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Clinical pictures:
usually there are two phases 1- Aura: It lasts 15 - 30 minutes before the onset of headache, it is usually visual, it my be sensory e.g. tingling in the hand spreading slowly up wards to involve the lips and tongue, rarely consist dysphasia or hemiparesis .

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2- Headach:
Its duration usually several hours, but rarely it remains for 2 - 3 days, It starts in localized area on one side (often the temple) and gradually spreads to the whole head .It sometimes radiates into the neck or the face due to involvement of the occipital and facial vessels. It is thropping in character, Intensified by all forms of

exertion and my be associated with nausea and vomiting

.
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Others rare type of migraine

1- Ophthalmic migraine: which is recurrent attacks of headache associated with paralysis of one or more ocular nerve which persist for days or week after the attack and tends to become permanent .Probably it is due to oedema of the wall of the internal carotid artery with pressure on

the ocular nerves in the wall of cavernous sinus .

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2- Basilar artery migraine:

It is due to involvement the branches of the basilar artery leading to disturbance of brain stem function during the attack leading to giddiness, ataxia, vertigo, dysartheria and even short period of loss of consciousness .

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