Headache

Headache

Headache is one of the most common symptoms in medicine and may account for up to 40% of neurological consultations. There is a great deal of overlap in the presentations of headache, and although the characteristic features of particular types of headache will be presented in this class, it is important to bear in mind that, in practice, symptoms are often not as clear-cut.

TENSION HEADACHE

Tension headache is the commonest form of headache and is experienced by most people at some point in their lives.

There is a diffuse, “band like”, dull headache, which may be accompanied by scalp tenderness and be aggravated by noise and light. It may last hours to days. It may be infrequent or daily, and is usually worse towards the end of the day. There are no abnormal physical signs.

Treatment is with reassurance, analgesia, physical treatment (massage, relaxation therapy), and antidepressants when indicated. Paradoxically, these headaches can be exacerbated by analgesic overuse (analgesic abuse), especially codeinecontaining drugs, and thus stopping these drugs may help.

MIGRAINE

Migraine is a common, often familial, condition characterized by an episodic unilateral throbbing headache lasting 1—24hours. It is much more common in women, especially when young. There is often a visual prodrome with fortification spectra or flashing lights.

The headache is thought to have a vascular component and to be related to the release of vasoactive substances. The level of serum 5hydroxytryptamine (5HT) rise with the prodromal symptoms and falls during the headache.

There are various subdivisions of migraine, although classical and common migraine are the most frequently encountered forms.

Classical migraine

In classical migraine, an aura, which is usually visual, precedes the headache. Typically, the headache is unilateral and throbbing, accompanied by nausea and vomiting, and aggravated by light (photophobia) and relieved by sleep in a darkened room.

Common migraine

In common migraine, there is no aura. The headache is similar to a classical migraine, but may be more indistinct and merge more with tension headache.

Basilar migraine

In basilar migraine, the prodomal symptoms result from dysfunction in the territory of the posterior cerebral circulation, with bilateral visual symptoms, ataxia, dysarthria, vertigo, limb paraesthesiae, and even weakness. There may be loss of consciousness prior to the onset of headache.

Hemiplegic migraine

Hemiplegic migraine is rare and involves hemiplegia that can persist for days after the headache has settled. In some cases there is an autosomal dominant transmission.

Ophthalmoplegic migraine

Extraocular palsies, usually the third nerve, occurring with a migraine constitute ophthalmoplegic migraine. This is rare and difficult to differentiate from other causes of third nerve palsy.

DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS  The diagnosis is usually made from the history, as there are usually no clinical findings in the commoner forms of migraine.  The headache needs to be differentiated from meningitis and subarachnoid haemorrhage, as both these require prompt treatment.  Hemiplegic migraine must be differentiated from stroke or transient ischaemic attacks.

MANAGEMENT

The patient needs to be reassured. Avoidance of any precipitating dietary factors (e.g. chocolate cheese) may be helpful. For patients taking oral contraceptives, changing the brand or stopping the drug may be required.

During an attack

 Antiemetics are often required to allow ingestion of other drug such as simple analgesics (e.g. paracetamol) or stronger analgesics (e.g. codeine-containing drugs).  Attacks may be terminated by the use of 5-HT agonists. Ergotamine is now rarely used , because of more frequent side effects.

Prophylaxis

For frequent and severe attacks, regular daily treatment may be required to prevent their onset. Commonly used drugs includes:

 Propranolol (beta-adrenergic-receptor blockor)  Antidepressants, especially tricyclics (e.g. amitriptyline).  Pizotifen (5-HT antagonist)  Methysergide (5-HT antagonist)---rarely used now as it causes retroperitoneal fibrosis.

CLUSTER HEADACHE

Cluster headache is a characteristic headache syndrome that occurs more commonly in men, with an onset in early middle life.

Features Features of cluster headache comprise severe unilateral pain localized around the eye with unilateral.  Conjunctival injection  Lacrimation  Rhinorrhoea  With or without transient Horner’s syndrome

The headache and associated features last between 10 minutes and 2 hours, typically occurring one to three times daily in clusters lasting weeks or a few months at a time. Interval between clusters may extend to several years. Onset of an attack is often in the early hours of the morning, waking the patient from sleep.

Treatment

Treatments used in migraine , particularly sumatriptan and ergotamine , can be helpful in cluster headache.

Specific treatments include a course of corticosteroids (e.g. 60mg of prednisolone for 5-10 days), inhaled oxygen, indomethacin and verapamil. Methysergide can be used for resistant cases, but under hospital supervision as it can cause retroperitoneal fibrosis. Lithium can be useful if the symptoms are more chronic, however levels need to be monitored.

GIANT-CELL ARTERITIS

Giant-cell arteritis is a granulomatous arteritis, usually affecting the superficial temporal artery in those over 60 years old. The majority of patients experience pain over the thickened, tender, often non-pulsatile, temporal artery. The headache is accompanied by:

 A raised ESR----often marked(60-100)  Visual lost (25% of untreated cases): amaurosis fugax (a transient ischaemic attack involving the retinal vessels). Permanent visual loss due to inflammation or occlusion of the ciliary or retinal vessels  Jaw claudication

 Systemic feature : prximal muscle pain--polymyalgia rheumatica (up to 50% of cases), weight loss, lassitude.  Rarer complications: brainstem ischaemia, cortical blindness, cranial nerve lesions, aortitis, involvement of coronary and mesenteric arteries.

Diagnosis

The diagnosis is made from the history and a raised ESR. It is confirmed by a biopsy of the temporal artery (at least 1cm, as the diseases process may be patchy).

Treatment

The treatment is with high-dose corticosteroids, e.g. prednislolone 60mg. There is a risk of blindness if treatment is delayed, hence the steroids should be started immediately, prior to the biopsy. The dose is reduced as the ESR falls. It is usually possible to withdraw steroids slowly after several months to years.