Headache symptom, migraine
he causes of headaches (cephalalgia) are extremely diverse. The main of them – diseases of the brain and the membranes (hydrocephalus, encephalopathy), outside of the cranial cavity organs – soft tissue of the neck, paranasal sinuses, eyes, or other conditions - angioneurosis, internal diseases, chronic and acute intoxication, etc.
The lesion of the meninges (meningitis, arachnoiditis, subarachnoid hemorrhage, brain injury) entails a headache due to mechanical irritation of the meningeal branches of the trigeminal nerve receptors, and in some cases and impairments of the circulation of cerebrospinal fluid from increased intracranial pressure. Impaired circulation of cerebrospinal fluid with a change in intracranial pressure in the direction of its increase is a major factor headache occurring during the process of restricting the space (brain tumors, abscesses).
With hypertension, migraine, hypotension based headaches are disorders of blood circulation in the basins of internal and external carotid arteries. As a result of lowering the tone of cerebral arteries pulse wave causes excessive stretching of its walls and in the investigation of this man formed a sense of headaches. Also has a value of stagnation that occurs in the capillaries.
Involvement in the pathological process of the nerves innervating the soft tissue of the head, the lining of the brain, brain vessels (trigeminal, vagal, C1–C3 spinal nerve roots, cervical sympathetic ganglia), is another pathogenetic factor of headache.
It is important to determine the nature, location, duration of headache, the time of its occurrence.
Distinguish pressing, drawing, piercing, pulsating, stabbing and shooting headaches. The localization of the headache associated with the location and nature of the pathological process. Irritation of the meninges, trigeminal nerve usually causes a local headache.
More diffuse vegetative pain, but I find their preferential localization in a certain area of the vessel. Thus, when the damage of the internal carotid or ophthalmic artery pain occurs more frequently in the forehead, eye sockets, eyeballs, the root of the nose. Pain associated with vertebral artery, are projected in the neck and neck.
In addition to local, can be a pain, exciting the whole head or half. For the duration distinguish permanent and paroxysmal headaches. Time of occurrence of headache is not the same: morning, afternoon, evening, night.
Long-term, persistent, intense pain arising in lesions of the meninges. When meningitis and subarachnoid hemorrhage are more diffuse than in arachnoiditis.
An important tool for diagnosis is the combination of headache with the meningeal syndrome. Their expression is determined by the proximity of the process to the shells (in these cases can be observed, and local pain) and degree of intracranial hypertension. Only in early disease headache can be paroxysmal, then it becomes a constant, very intense, sometimes growing at night.
Focal neurological symptoms, hypertensive effects in the fundus and radiographs of the skull bones, electroencephalogram, changes in the cerebrospinal fluid can clarify the origin of headaches.
Often headaches are observed in hydrocephalus. For all the headaches that arise as a result of hypertensive syndrome, characterized by their increased when turning the eyes, sudden head movements, coughing, straining.
Arterial hypertension characterized by dull, pressing, throbbing headache, worse physical and mental stress. It may be noted, in some cases, some of the connections between the severity of headaches and blood pressure level, but pain also occurs at the sudden pressure decrease. The level of blood pressure changes from the side of the heart and angiospastic picture fundus help correct diagnosis.
Hypertension headaches are less intense and are usually accompanied by general weakness, feeling of weakness, decreased performance. Quite typical unilateral paroxysmal pain in migraine, paroxysmal attacks of sharp pain associated with trigeminal neuralgia, rarely with pterygopalatine ganglion and occipital nerves.
Headaches may develop and in eye diseases. First of all, you need to remember about glaucoma and suspected it to investigate the intraocular pressure. Pain occurs with iritis and as a result of impaired refraction. In the latter case, the selection of appropriate glasses eliminates pain. For the whole of this group is characterized as a localized headache in the forehead.
The cause of headaches can also be inflammatory diseases of the sinuses (frontal sinusitis, ethmoiditis, sinusitis, purulent otitis media). Diagnosis of this type of pain is usually facilitated by their localization, X-ray data, and data from an otolaryngologist's study. Local headaches may be due to impaired intestinal activity (constipation), liver, kidneys (uremia).
Headaches are a common symptom of acute febrile illness. In many visceral diseases, there is a constant, diffuse, moderately severe headache. In children, the helminthic invasion may be the cause of headache.
Headache and migraine classification
The secondary headaches
Cranial neuralgias central and primary facial pain and other headaches
Headache and migraine diagnosis
If there are complaints of a prolonged or chronic, as well as acute headache, it may be necessary to consult a neuropathologist for advice first. According to the results of a neurological examination, an accurate diagnosis can already be made. If the diagnosis is preliminary, then the patient will be given additional diagnostic appointments.
- cerebrovascular Doppler ultrasonography, REG, EhoEG
- skull and cervical spines x-ray examination
- brain MRI
- brain CT
- cerebrovascular MR-angiography
- cervical spine MRI
- lumbar puncture (LP) for cerebrospinal fluid (CSF) analysis
There are many diagnostic tests and procedures, application of which is widespread in clinical practice, but they are not always required for the diagnosis of headache and migraine.
- Patients with stable headache, that meets migraine criteria, does not require neuroimaging studies. The probability of detecting any organic pathology in these patients is extremely low. Neuroimaging studies are expensive and have unnecessary radiation exposure on the body. In addition, diagnosis of possible random findings (congenital cerebrovascular and vertebral anomalies), will cause (or effort) anxiety in a patient, while these findings are not clinically significant.
- Computed tomography (CT) in patients with headache dose not indicated, if magnetic resonance imaging (MRI) is available, except emergencies (third cerebral ventricle colloid cyst with acute occlusion hydrocephalus). If the headache is sudden and increases, the best option is magnetic resonance imaging (MRI), because of it is not associated with patient radiation exposure and identifies more brain’s pathological conditions.
- Without pre-clinical studies is not recommended use surgical treatment on the trigger points in migraine (deactivation procedure), because this type of treatment are still in the experimental stages. In this situation is preferred drug therapy rather than surgery.
- In the case of recurring headache as first aid for their relieving symptoms should not use opioids or barbiturates substitute drugs. Their frequent use gives sedation and somnolence, and causes addiction. Therefore, these drugs are best to have as reserve preparations for situations when other medicines (triptans, NSAIDs) does not relieve the pain or contraindicated in patients.
- For headache symptoms relieve dose not recommended independent prolonged or frequent use of OTC drugs. In such a situation patient must communicate with doctor for best treatment options.
The management of rare trigeminal autonomic cephalalgias
Differentiation of trigeminal-autonomic cephalalgias:
Type of trigeminal autonomic cephalalgias
|Continuous pain with exacerbations
|Duration: 15-180 min (usually 30-60 min)
Frequency: 0.5-8 per day (mean, 4 per day)
|Duration: 2-30 min (mean, 26 min)
Frequency: 5-40 per day (mean, 15 per day)
|Duration: 5-600 s (usually 10-120 s; mean, 60 s)
Frequency: 3-200 per day (mean, 28 per day)
SUNCT - short-lasting unilateral neuralgiform headache with conjunctival injection and tearing, SUNA - short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms.
Therapeutic approaches based on target structure and mechanism of action:
Mechanism of action
|Somatosensory cortex and Thalamus
|Thalamocortical sensory processing
|- CGRP pathway blockers
|Superior salivary nucleus
|- Origin of cranial autonomic symptoms
- Connection to sphenopalatine ganglion
|- Vagal nerve stimulation
- Sphenopalatine ganglion stimulation
- COX inhibitors
- CGRP pathway blockers
|Convergence of upper cervical nerves (e.g., greater occipital nerve) with trigeminal nucleus
|- Greater occipital nerve neuromodulation
- Greater occipital nerve block (lidocaine)
CGRP - сalcitonin gene-related peptide, COX - Cyclooxygenase.
Headache and migraine treatment
After an accurate diagnosis is established, depending on the severity of the manifestation of the disease, the patient will be offered conservative or surgical treatment, depending on the identified disease.
Depending on the severity of the manifestations and the causes of the symptom of a headache in a patient, the following therapeutic actions are possible: