Headache and migraine symptoms, diagnosis and treatment
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 primary headaches
- Migraine without aura
- Migraine with aura
- Typical aura with migraine headache
- Typical aura with non-migraine headache
- Typical aura without headache
- Familial hemiplegic migraine (FHM)
- Sporadic hemiplegic migraine
- Basilar-type migraine
- Childhood periodic syndromes that are commonly precursors of migrain
- Cyclical vomiting
- Abdominal migraine
- Benign paroxysmal vertigo of childhood
- Retinal migraine
- Complications of migraine
- Chronic migraine
- Status migrainosus
- Persistent aura without infarction
- Migrainous infarction
- Migraine-triggered seizure
- Probable migraine
- Probable migraine without aura
- Probable migraine with aura
- Probable chronic migraine
- Infrequent episodic tension-type headache
- Infrequent episodic tension-type headache associated with pericranial tenderness
- Infrequent episodic tension-type headache not associated with pericranial tenderness
- Frequent episodic tension-type headache
- Frequent episodic tension-type headache associated with pericranial tenderness
- Frequent episodic tension-type headache not associated with pericranial tenderness
- Chronic tension-type headache
- Chronic tension-type headache associated with pericranial tenderness
- Chronic tension-type headache not associated with pericranial tenderness
- Probable tension-type headache
- Probable infrequent episodic tension-type headache
- Probable frequent episodic tension-type headache
- Probable chronic tension-type headache
- Cluster headache
- Episodic cluster headache
- Chronic cluster headache
- Paroxysmal hemicrania
- Episodic paroxysmal hemicrania
- Chronic paroxysmal hemicrania (CPH)
- Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT)
- Probable trigeminal autonomic cephalalgia
- Probable cluster headache
- Probable paroxysmal hemicrania
- Probable short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing
- Primary stabbing headache
- Primary cough headache
- Primary exertional headache
- Primary headache associated with sexual activity
- Preorgasmic headache
- Orgasmic headache
- Hypnic headache
- Primary thunderclap headache
- Hemicrania continua
- New daily-persistent headache (NDPH)
The secondary headaches
- Acute post-traumatic headache
- Acute post-traumatic headache attributed to moderate or severe head injury
- Acute post-traumatic headache attributed to mild head injury
- Chronic post-traumatic headache
- Chronic post-traumatic headache attributed to moderate or severe head injury
- Chronic post-traumatic headache attributed to mild head injury
- Acute headache attributed to whiplash injury
- Chronic headache attributed to whiplash injury
- Headache attributed to traumatic intracranial haematoma
- Headache attributed to epidural haematoma
- Headache attributed to subdural haematoma
- Headache attributed to other head and/or neck trauma
- Acute headache attributed to other head and/or neck trauma
- Chronic headache attributed to other head and/or neck trauma
- Post-craniotomy headache
- Acute post-craniotomy headache
- Chronic post-craniotomy headache
- Headache attributed to ischaemic stroke or transient ischaemic attack
- Headache attributed to ischaemic stroke (cerebral infarction)
- Headache attributed to transient ischaemic attack (TIA)
- Headache attributed to non-traumatic intracranial haemorrhage
- Headache attributed to intracerebral haemorrhage
- Headache attributed to subarachnoid haemorrhage (SAH)
- Headache attributed to unruptured vascular malformation
- Headache attributed to saccular aneurysm
- Headache attributed to arteriovenous malformation (AVM)
- Headache attributed to dural arterio-venous fistula
- Headache attributed to cavernous angioma
- Headache attributed to encephalotrigeminal or leptomeningeal angiomatosis (Sturge Weber syndrome)
- Headache attributed to arteritis
- Headache attributed to giant cell arteritis (GCA)
- Headache attributed to primary central nervous system (CNS) angiitis
- Headache attributed to secondary central nervous system (CNS)
- Carotid or vertebral artery pain
- Headache or facial or neck pain attributed to arterial dissection
- Post-endarterectomy headache
- Carotid angioplasty headache
- Headache attributed to intracranial endovascular procedures
- Angiography headache
- Headache attributed to cerebral venous thrombosis (CVT)
- Headache attributed to other intracranial vascular disorder
- Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL)
- Mitochondrial encephalopathy, lactic acidosis and stroke-like episodes (MELAS)
- Headache attributed to benign (or reversible) angiopathy of the central nervous system
- Headache attributed to pituitary apoplexy
- Headache attributed to high cerebrospinal fluid pressure
- Headache attributed to idiopathic intracranial hypertension (IIH)
- Headache attributed to intracranial hypertension secondary to metabolic, toxic or hormonal causes
- Headache attributed to intracranial hypertension secondary to hydrocephalus
- Headache attributed to low cerebrospinal fluid pressure
- Post-dural (post-lumbar) puncture headache
- CSF fistula headache
- Headache attributed to spontaneous (or idiopathic) low CSF pressure
- Headache attributed to non-infectious inflammatory disease
- Headache attributed to neurosarcoidosis
- Headache attributed to aseptic (non-infectious) meningitis
- Headache attributed to other non-infectious inflammatory disease
- Headache attributed to lymphocytic hypophysitis
- Headache attributed to intracranial neoplasm
- Headache attributed to increased intracranial pressure or hydrocephalus caused by neoplasm
- Headache attributed directly to neoplasm
- Headache attributed to carcinomatous meningitis
- Headache attributed to hypothalamic or pituitary hyper- or hyposecretion
- Headache attributed to intrathecal injection
- Headache attributed to epileptic seizure
- Hemicrania epileptica
- Post-ictal headache
- Headache attributed to Chiari malformation type I (CM1)
- Syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis (HaNDL)
- Headache attributed to other non-vascular intracranial disorder
- Headache induced by acute substance use or exposure
- Nitric oxide (NO) donor-induced headache
- Immediate NO donor-induced headache
- Delayed NO donor-induced headache
- Phosphodiesterase (PDE) inhibitor-induced headache
- Carbon monoxide-induced headache
- Alcohol-induced headache
- Immediate alcohol-induced headache
- Delayed alcohol-induced headache
- Headache induced by food components and additives
- Monosodium glutamate-induced headache
- Cocaine-induced headache
- Cannabis-induced headache
- Histamine-induced headache
- Immediate histamine-induced headache
- Delayed histamine-induced headache
- Calcitonin gene-related peptide (CGRP)-induced headache
- Immediate CGRP-induced headache
- Delayed CGRP-induced headache
- Headache as an acute adverse event attributed to medication used for other indications
- Headache attributed to other acute substance use or exposure
- Nitric oxide (NO) donor-induced headache
- Medication-overuse headache (MOH)
- Ergotamine-overuse headache
- Triptan-overuse headache
- Analgesic-overuse headache
- Opioid-overuse headache
- Combination analgesic-overuse headache
- Medication-overuse headache attributed to combination of acute medications
- Headache attributed to other medication overuse
- Probable medication-overuse headache
- Headache as an adverse event attributed to chronic medication
- Exogenous hormone-induced headache
- Headache attributed to substance withdrawal
- Caffeine-withdrawal headache
- Opioid-withdrawal headache
- Oestrogen-withdrawal headache
- Headache attributed to withdrawal from chronic use of other substances
- Headache attributed to intracranial infection
- Headache attributed to bacterial meningitis
- Headache attributed to lymphocytic meningitis
- Headache attributed to encephalitis
- Headache attributed to brain abscess
- Headache attributed to subdural empyema
- Headache attributed to systemic infection
- Headache attributed to systemic bacterial infection
- Headache attributed to systemic viral infection
- Headache attributed to other systemic infection
- Headache attributed to HIV/AIDS
- Chronic post-infection headache
- Chronic post-bacterial meningitis headache
- Headache attributed to hypoxia and/or hypercapnia
- High-altitude headache
- Diving headache
- Sleep apnoea headache
- Dialysis headache
- Headache attributed to arterial hypertension
- Headache attributed to phaeochromocytoma
- Headache attributed to hypertensive crisis without hypertensive encephalopathy
- Headache attributed to hypertensive encephalopathy
- Headache attributed to pre-eclampsia
- Headache attributed to eclampsia
- Headache attributed to acute pressor response to an exogenous agent
- Headache attributed to hypothyroidism
- Headache attributed to fasting
- Cardiac cephalalgia
- Headache attributed to other disorder of homoeostasis
- Headache attributed to disorder of cranial bone
- Headache attributed to disorder of neck
- Cervicogenic headache
- Headache attributed to retropharyngeal tendonitis
- Headache attributed to craniocervical dystonia
- Headache attributed to disorder of eyes
- Headache attributed to acute glaucoma
- Headache attributed to refractive errors
- Headache attributed to heterophoria or heterotropia (latent or manifest squint)
- Headache attributed to ocular inflammatory disorder
- Headache attributed to disorder of ears
- Headache attributed to rhinosinusitis
- Headache attributed to disorder of teeth, jaws or related structures
- Headache or facial pain attributed to temporomandibular joint (TMJ) disorder
- Headache attributed to other disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cervical structures
- Headache attributed to somatisation disorder
- Headache attributed to psychotic disorder
Cranial neuralgias central and primary facial pain and other headaches
- Trigeminal neuralgia
- Classical trigeminal neuralgia
- Symptomatic trigeminal neuralgia
- Glossopharyngeal neuralgia
- Classical trigeminal neuralgia
- Symptomatic trigeminal neuralgia
- Nervus intermedius neuralgia
- Superior laryngeal neuralgia
- Nasociliary neuralgia
- Supraorbital neuralgia
- Other terminal branch neuralgias
- Occipital neuralgia
- Neck-tongue syndrome
- External compression headache
- Cold-stimulus headache
- Headache attributed to external application of a cold stimulus
- Headache attributed to ingestion or inhalation of a cold stimulus
- Constant pain caused by compression, irritation or distortion of cranial nerves or upper cervical roots by structural lesions
- Optic neuritis
- Ocular diabetic neuropathy
- Head or facial pain attributed to herpes zoster
- Head or facial pain attributed to acute herpes zoster
- Post-herpetic neuralgia
- Tolosa-Hunt syndrome
- Ophthalmoplegic “migraine”
- Central causes of facial pain
- Anaesthesia dolorosa
- Central post-stroke pain
- Facial pain attributed to multiple sclerosis
- Persistent idiopathic facial pain
- Burning mouth syndrome
- Other cranial neuralgia or other centrally-mediated facial pain
- Headache not elsewhere classified
- Headache unspecified
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
Brain magnetic resonance imaging (MRI) used in patients with headaches attributed to increased intracranial pressure or hydrocephalus.
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 |
Clinical Presentation |
Hemicrania continua | Continuous pain with exacerbations |
Cluster headache | Duration: 15-180 min (usually 30-60 min) Frequency: 0.5-8 per day (mean, 4 per day) |
Paroxysmal hemicrania | Duration: 2-30 min (mean, 26 min) Frequency: 5-40 per day (mean, 15 per day) |
SUNCT/SUNA | 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:
Target structure |
Mechanism of action |
Therapy options |
Somatosensory cortex and Thalamus | Thalamocortical sensory processing | - Topiramate - Carbamazepine - Lamotrigine |
Hypothalamus | - CGRP pathway blockers - Verapamil - Steroids |
|
Superior salivary nucleus | - Origin of cranial autonomic symptoms - Connection to sphenopalatine ganglion |
- Vagal nerve stimulation - Sphenopalatine ganglion stimulation - Indomethacin |
Trigeminal nucleus | Trigeminovascular system | - Topiramate - Carbamazepine - COX inhibitors - OnabotulinumtoxinA - Lidocaine - CGRP pathway blockers - Indomethacin |
Trigeminocervical nucleus | 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:
- drug therapy (NSAIDs, analgesics, hormones)
- trigger point injection in the neck muscles
- lumbar puncture
- physiotherapy
- occupational therapy
- reflexotherapy (acupuncture)
- surgical treatment
See also
- Anatomy of the nervous system
- Central nervous system infection:
- Brain abscess (lobar, cerebellar)
- Eosinophilic granuloma, Langerhans cell histiocytosis (LCH), Hennebert's symptom
- Epidural brain abscess
- Sinusitis-associated intracranial complications
- Otogenic intracranial complications
- Sinusitis-associated ophthalmic complications
- Bacterial otogenic meningitis
- Subdural brain abscess
- Sigmoid sinus suppurative thrombophlebitis
- Cerebral 3 ventricle colloid cyst
- Cerebral and spinal adhesive arachnoiditis
- Encephalopathy
- Headache, migraine
- Traumatic brain injury (concussion, contusion, brain hemorrhage, axonal shearing lesions)
- Increased intracranial pressure and hydrocephalus
- Parkinson's disease
- Pituitary microadenoma, macroadenoma and nonfunctioning adenomas (NFPAs), hyperprolactinemia syndrome
- Spontaneous cranial cerebrospinal fluid leak (CSF liquorrhea)