Headache

Snapshot

• A 33-year-old woman presents to her primary care physician with headache, nausea, and visual disturbances. The patient was in her usual state of health until yesterday, when she experienced a pulsatile bilateral headache that caused her to have one episode of emesis. Her headache is accompanied by seeing a shimmering light that distorts her vision, photophobia, and phonophobia. Medical history is unremarkable, and the patient recently began menses. Ibuprofen and acetaminophen have not improved her symptoms. Neurologic examination is unremarkable. (Migraine headaches)

Introduction

• Headache is a common neurologic symptom that can be divided into
  • primary and secondary headache disorders
    • primary headaches include
      • tension-type headache
      • migraine headache
      • cluster headache
    • secondary headaches describe a headache caused by some other etiology such as
      • space occupying lesions
        • e.g., brain tumor, hematoma, and hydrocephalus
      • severe hypertension
      • cerebral venous thrombosis
      • pre-eclampsia
      • vasculitic syndromes
        • e.g., giant cell arteritis
      • head trauma
      • subarachnoid hemorrhage
      • infections
        • e.g., meningitis and encephalitis
• Note that the brain parenchyma does not have pain receptors
  • therefore, pain leading to the headache is the result of
    • insults (e.g., inflammation or irritation) affecting innervated head structures such as the
      • meninges
      • scalp
      • skull
      • blood vessels
• Warning signs for a secondary headache caused by a serious underlying etiology includes
  • systemic symptoms
    • e.g., weight loss, fever, and an immunocompromised state
  • neurologic symptoms
    • e.g., confusion, altered consciousness, papilledema, and focal neurologic deficits
  • onset of headache
    • new type or sudden headache
  • other
    • e.g., head trauma, illicit drug use, headaches that awakens the patient from sleep, headaches that worsens with valsalva maneuvers, and change in headache patterns

Primary Headache Disorders

Other Headaches

• Trigeminal neuralgia (tic douloureux) 
  • clinical definition
    • a headache disorder secondary to disruption of the
      • second (V2) and third (V3) branch of the trigeminal nerve
  • presentation
    • recurrent and brief episodes of pain most commonly in the distribution of V2 and/or V3
    • these headaches are often triggered by
      • chewing
      • shaving
      • touching or a breeze affecting the V2 and/or V3 distrubution
  • etiology
    • vascular compression
    • malignancy affecting the nerve
      • or any other cause such as
        • a plaque of multiple sclerosis
  • treatment
    • carbamazepine
    • oxcarbazepine