Headache is a pain symptom anywhere in the head or neck region. It occurs in migraine (sharp or throbbing pain), tension-type headache, and cluster headache. Frequent headaches can affect relationships and work. There is also an increased risk of depression in those with severe headaches.
Headache can occur as a result of many conditions whether serious or not. There are a number of different classification systems for headaches. The best known are the International Headaches Society. Causes of headaches may include dehydration, fatigue, sleep deprivation, stress, drug effects, the effects of recreational drugs, viral infections, loud noise, colds, head injuries, rapid consumption of cold foods or drinks, and teeth or sinus problems.
Headache treatment depends on the underlying cause, but generally involves pain medication. Headache is one of the most commonly experienced of all physical discomfort.
About half of adults experience headaches in a given year. Tension headaches are the most common, affecting about 1.6 billion people (21.8% of the population) followed by migraine headaches that affect about 848 million (11.7%).
Video Headache
Cause
There are more than 200 types of headaches. Some are harmless and some are life-threatening. Description of headache and findings on neurologic examination, determine whether additional testing is needed and what treatment is best.
Primary headache vs. secondary
Headaches are broadly classified as "primary" or "secondary". Primary headaches are benign, recurrent headaches not caused by underlying disease or structural problems. For example, migraine is a type of primary headache. While primary headaches can cause significant day-to-day pain and disability, they are harmless. Secondary headaches are caused by an underlying disease, such as infection, head injury, vascular disorders, cerebral hemorrhage or tumors. Secondary headaches can be harmless or harmful. A "danger sign" or a warning sign indicating a secondary headache may be dangerous.
Primary headache
90% of all headaches are primary headache. Primary headaches are usually first started when people are between the ages of 20 and 40 years. The most common primary headache types are migraine and tension-type headache. They have different characteristics. Migraines usually present with a throbbing headache, nausea, photophobia (sensitivity to light) and phonophobia (sensitivity to sound). Tension-type headache is usually present with non-pulse "bandlike" pressure on both sides of the head, not accompanied by other symptoms. Other very rare types of headaches include:
- cluster headache: short episodes (15-180 minutes) severe pain, usually around one eye, with autonomic symptoms (tearing, red eyes, nasal congestion) occurring at the same time each day. Cluster headaches can be treated with triptans and prevented by prednisone, ergotamine or lithium.
- trigeminal neuralgia or occipital neuralgia: shooting facial pain
- hemicrania continua: continuous unilateral pain with severe episodes of pain. Continuous Hemicrania can be relieved by the drug indomethacin.
- primary stabbing headache: recurrent episodes of "pain" or jabs and jolts for 1 sec to several minutes without autonomic symptoms (tearing, red eyes, nasal congestion).This headache can be treated with indomethacin.
- Primary cough headache: starts suddenly and lasts for several minutes after coughing, sneezing or straining (anything that can increase the pressure on the head). Serious causes (see head red section of secondary headache) should be ruled out before the diagnosis of a "benign" cough headache can be done.
- Major executive headaches: pulsed, pulsatile pain that begins during or after exercise, lasts for 5 minutes to 24 hours. The mechanism behind these headaches is unclear, perhaps because the straining causes the veins in the head to dilate, causing pain. These headaches can be prevented by not exercising too hard and can be treated with drugs such as indomethacin.
- primary sex headaches: boring, bilateral headaches that begin during sexual activity and become much worse during orgasm. This headache is thought to be due to lower pressure on the head during sex. It is important to realize that headaches that are started during orgasm may be caused by subarachnoid hemorrhage, so the serious cause should be ruled out first. This headache is treated by counseling the person to stop having sex if they have headaches. Drugs such as propranolol and diltiazem may also be helpful.
- hypnic headache: moderate-severe headache that begins several hours after falling asleep and lasts 15-30 minutes. Headaches can recur several times during the night. Hypertension headaches usually occur in older women. They may be treated with lithium.
Secondary headache
Headaches may be caused by problems elsewhere in the head or neck. Some of them are harmless, such as cervicogenic headaches (pain arising from the neck muscles). Drugs overuse of headaches can occur in those who use excessive painkillers for headaches, paradoxically causing a worsening headache.
The causes of more serious secondary headaches include:
- meningitis: inflammation of meninges with fever and meningism, or stiff neck
- bleeding in the brain (intracranial hemorrhage)
- subarachnoid hemorrhage (acute, severe headache, stiff neck WITHOUT fever)
- ruptured aneurysms, arteriovenous malformations, intraparenchymal bleeding (headache only)
- Brain tumor: dull headache, worsens with exertion and position changes, accompanied by nausea and vomiting. Often, the person will experience nausea and vomiting for weeks before the headache begins.
- temporal arteritis: common arterial inflammatory disease in the elderly (mean age 70) with fever, headache, weight loss, claudication jaw, soft veins by temples, polymyalgia rheumatica
- acute closed angle glaucoma (increased pressure on the eyeball): headache that begins with eye pain, blurred vision, associated with nausea and vomiting. On physical examination, the person will have red eyes and a fixed mid pupil.
- Post-ictal headaches: Headaches that occur after seizures or other types of seizures, as part of the period after seizure (post-ictal state)
Gastrointestinal disturbances can cause headaches, including Helicobacter pylori infection, celiac disease, non-celiac gluten sensitivity, irritable bowel syndrome, inflammatory bowel disease, gastroparesis, and hepatobiliary disorders. Treatment of gastrointestinal disorders may cause remission or increased headache.
Maps Headache
Pathophysiology
The brain itself is insensitive to pain, because it lacks pain receptors. However, some areas of the head and neck have pain receptors and thus can feel the pain. These include extracranial arteries, middle meningeal arteries, large blood vessels, venous sinuses, cranial and spinal nerves, head and neck muscles, meninges, falx cerebri, brainstem parts, eyes, ears, teeth and lining the mouth. The arterial artery, rather than the pial vein is responsible for the production of pain.
Headaches are often caused by the pull or irritation of the meninges and blood vessels. Nociceptors can be stimulated by head or tumor trauma and cause headaches. Seizures of blood vessels, dilated blood vessels, inflammation or infection of the meninges and muscle tension can also stimulate nociceptors and cause pain. Once stimulated, a nociceptor sends a message along the nerve fibers to the nerve cells in the brain, indicating that the body part hurts.
Primary headaches are more difficult to understand than secondary headaches. The exact mechanisms that cause migraines, tense headaches, and cluster headaches are unknown. There are different theories from time to time that try to explain what's going on in the brain to cause this headache.
Migraine is presently thought to be caused by nerve dysfunction in the brain. Previously, migraines were thought to be caused by a major problem with blood vessels in the brain. This vascular theory, developed in the 20th century by Wolff, shows that the aura of migraine is caused by the narrowing of the intracranial vessels (the vessels in the brain), and the headache itself is caused by the widening of extracranial vessel rebounds (vessels outside the brain). The dilation of these extracranial veins activates the pain receptors around the nerves, causing headaches. Vascular theory is no longer accepted. Studies have shown migraine headaches are not accompanied by extracranial vasodilation, but only have some mild intracranial vasodilation.
Nowadays, most specialists think migraines are caused by major problems with nerves in the brain. Aura is thought to be caused by a surge in activity of neurons in the cerebral cortex (part of the brain) known as cortical spread depression followed by periods of depression activity. Some people think headaches are caused by activation of the sensory nerves that release peptides or serotonin, causing inflammation in the arteries, dura and meninges and also causing some vasodilation. Triptans, drugs that treat migraines, block serotonin receptors and constrict blood vessels.
People who are more susceptible to headaches without migraines are those who have a family history of migraines, women, and women who undergo hormonal changes or are taking birth control pills or are given hormone replacement therapy.
Tension headache is thought to be caused by peripheral nerve activation in the head and neck muscles
Cluster headaches involve the overactivation of trigeminal and hypothalamic nerves in the brain, but the exact cause is unknown.
Diagnostic approach
Most headaches can be diagnosed only with a clinical history. If the symptoms described by the person sound dangerous, further testing with neuroimaging or lumbar puncture may be necessary. Electroencephalography (EEG) is not useful for the diagnosis of headaches.
The first step to diagnosing a headache is to determine whether the headache is old or new. The "new headache" can be a headache that has just begun, or a chronic headache that has changed character. For example, if a person experiences chronic weekly headaches with pressure on both sides of his head, and then develops a sudden headache pulsating suddenly on one side of his head, they experience a new headache.
Red flag
It can be a challenge to differentiate between low risk, benign headaches and high risk, dangerous headaches because the symptoms are often similar. Headaches that may be dangerous require further laboratory tests and imaging to be diagnosed.
American College for Emergency Physicians publishes criteria for low-risk headaches. They are as follows:
- younger than 30 years
- typical features of primary headache
- history of similar headaches
- no abnormal findings on neurological examination
- is not about changing the normal headache pattern
- no high-risk comorbid conditions (eg, HIV)
- nothing new about history or physical exam findings
A number of characteristics make it more likely that headaches are due to potentially harmful secondary causes that can be life-threatening or cause long-term damage. This "red flag" symptom means that headaches require further investigation with neuroimaging and laboratory tests.
In general, people complain about their "first" or "worst" headache imaging and further examination. People with worsening headaches also need imaging, as they may have mass or bleeding that gradually grows, squeezing the surrounding structures and causing worsening pain. People with neurologic findings on the exam, such as weakness, also need further examination.
The American Headache Society recommends using "SSNOOP", a mnemonic to remember red flags to identify secondary headaches:
- Systemic symptoms (fever or weight loss)
- Systemic disease (HIV infection, malignancy)
- Neurological symptoms or signs
- Sudden onset (thunderclap headache)
- Onset after age 40
- History of previous headaches (first, worst, or different headaches)
Other red flag symptoms include:
Old headache
The old headache is usually a primary and harmless headache. They are most commonly caused by migraines or tension headaches. Migraines are often unilateral, pulsing headaches accompanied by nausea or vomiting. There may be aura (visual symptoms, numbness or tingling) 30-60 minutes before headache, warning people with headaches. Migraine may also have no aura. Tension-type headaches usually have "bandlike" bilateral pressure on both sides of the head usually without nausea or vomiting. However, some symptoms of both groups of headaches can overlap. It is important to distinguish the two because the treatments are different.
'POUND' mnemonics help differentiate between migraine and tension-type headache. POUND stands for P ultile quality, 4-72 hours O length of urs, U nilateral location, N ausea or vomit, D activate the intensity. One review article found that if 4-5 POUND characteristics are present, migraine is 24 times more likely to be a diagnosis than a strained type of headache (24 chance ratio). If 3 characteristics of the MARKETS are present, migraine is 3 times more likely to be a diagnosis than a strained type of headache (possibly 3 ratios). If only 2 POUND characteristics are present, the tension type headache is 60% more likely (the likelihood ratio is 0.41). Other studies have found the following factors independently each increasing the likelihood of migraine headache for the tension-type headache: nausea, photophobia, phonophobia, exacerbation by physical activity, unilateral, pulsed quality, chocolate as a trigger headache, cheese as a headache trigger.
Cluster headaches are relatively rare (1 in 1000 people) and are more common in men than women. They come with explosive onset of sudden pain around one eye and are accompanied by autonomic symptoms (tearing, runny nose and red eyes).
Temporomandibular jaw pain (chronic pain in the jaw joint), and cervicogenic headache (headache caused by pain in the neck muscles) may also be a diagnosis.
For unexplained chronic headaches, storing diary headaches can be useful for tracking symptoms and identifying triggers, such as relationships with menstrual cycle, exercise, and diet. While mobile electronic diaries for smartphones are becoming increasingly common, the most recent reviews found are developed with a lack of evidence base and scientific expertise.
New headache
New headaches are more likely to become dangerous secondary headaches. They can, however, only be the first presentation of chronic headache syndrome, such as migraine or tension-type headache.
One recommended diagnostic approach is as follows. If there are urgent red flags such as vision loss, new seizures, new weaknesses, new confusion, further examination with imagery and possible lumbar punctures to be done (see red flag section for more details). If a sudden headache (thunderclap headache), a computer tomography test to look for brain bleeding (subarachnoid hemorrhage) should be performed. If a CT scan does not show bleeding, a lumbar puncture should be performed to look for blood in CSF, because CT scan can be wrong and subarachnoid hemorrhage can be fatal. If there are signs of infection such as fever, rash, or stiff neck, a lumbar puncture to look for meningitis should be considered. If there is a jaw claudication and scalp pain in an older person, a temporal artery biopsy to look for temporal arteritis should be performed and immediate treatment should begin.
Neuroimaging
Old headache
The US Headache Consortium has guidelines for neuroimaging a non-acute headache. The longest and chronic headache does not require neuroimaging. If a person has symptoms of migraine characteristics, neuroimaging is not necessary because it is highly unlikely that the person has an intracranial abnormality. If the person has neurological findings, such as weakness, on the exam, neuroimaging may be considered.
New headache
Everyone present with a red flag indicates a dangerous secondary headache should receive neuroimaging. The best form of neuroimaging for this headache is still controversial. Non-contrast computerized tomography (CT) scans are usually the first step in head imaging as they are available in the Emergency Department and hospitals and are cheaper than MRI. Non-contrast CT is best for identifying acute head bleeding. Magnetic resonance imaging (MRI) is best for brain tumors and problems in the posterior fossa, or back of the brain. MRI is more sensitive to identifying intracranial problems, but may take irrelevant brain abnormalities with a person's headache.
The American College of Radiology recommends the following imaging tests for different specific situations:
Lumbar puncture
Lumbar puncture is a procedure in which the cerebral spinal fluid is removed from the spine by a needle. Lumbar puncture is required to look for infections or blood in the spinal fluid. Lumbar punctures can also evaluate the pressure on the spine, which can be useful for people with idiopathic intracranial hypertension (usually young women, obese elevated intracranial pressure), or other causes of increased intracranial pressure. In most cases, CT scan should be done first.
Classification
The most correct headache is classified by International Headache Disorders (ICHD), which publishes the second edition in 2004. The third edition of the International Headache Classification was published in 2013 in beta before the final version. This classification is accepted by WHO.
Other classification systems exist. One of the first attempts published was in 1951. The US National Institutes of Health developed a classification system in 1962.
ICHD-2
The International Headache Disorders (ICHD) classification is an in-depth hierarchical classification of headaches published by the International Headache Society. It contains explicit (operational) diagnostic criteria for headache disorders. The first version of the classification, ICHD-1, was published in 1988. The current revision, ICHD-2, was published in 2004.
Classification uses numerical codes. The top one-digit diagnostic rate includes 14 headache groups. The first four are classified as primary headaches, groups 5-12 as secondary headaches, cranial neuralgia, central and primary facial pain and other headaches for the last two groups.
Classification ICHD-2 defines migraine, tension headache, cluster headache, and other trigeminal autonomic headache as the primary type of primary headache. Also, according to the same classification, stabbing headaches and headaches due to cough, physical activity and sexual activity (sexual headaches) are classified as primary headaches. Everyday headaches along with hypnic headaches and thunderclap headaches are considered a primary headache as well.
Secondary headaches are classified by cause and not the symptoms. According to the ICHD-2 classification, the main types of secondary headaches include those caused by head or neck trauma such as whiplash injury, intracranial hematoma, post craniotomy or head or neck injury. Headaches caused by cranial or cervical vascular disorders such as ischemic stroke and transient ischemic attacks, non-traumatic intracranial hemorrhage, vascular malformations or arteritis are also defined as secondary headaches. This type of headache can also be caused by cerebral venous thrombosis or different intracranial vascular disorders. Other secondary headaches are caused by non-vascular intracranial disturbances such as low or high pressure from cerebrospinal fluid pressure, inflammatory noninfectious disease, intracranial neoplasm, epilepsy seizures or other types of disorders or intracranial disease but not related to blood vessels of the central nervous system. ICHD-2 classifies headaches caused by consumption of certain substances or with withdrawal as secondary headaches as well. This type of headache may be caused by excessive use of some medications or due to exposure to some substances. HIV/AIDS, intracranial infections and systemic infections can also cause secondary headaches. The ICHD-2 classification system includes headaches associated with homeostatic disorders in the category of secondary headaches. This means headaches caused by dialysis, high blood pressure, hypothyroidism, and cephalalgia and even fasting are considered secondary headaches. Secondary headaches, according to the same classification system, can also be caused by injuries to the facial structure including teeth, jaws, or temporomandibular joints. Headaches caused by psychiatric disorders such as somatization or psychotic disorders are also classified as secondary headaches.
The ICHD-2 classification places cranial neuralgias and other neuralgia types in different categories. According to this system, there are 19 types of neuralgia and headaches due to different causes of facial pain center. In addition, ICHD-2 belongs to a category containing all headaches that can not be classified.
Although ICHD-2 is the most complete classification of headaches available and includes frequencies in the diagnostic criteria of some types of headaches (especially primary headaches), it does not specifically code the frequency or severity left at the discretion of the examiner.
NIH
The NIH classification consists of a short definition of a limited number of headaches.
The NIH classification system is more concise and only describes five categories of headaches. In this case, the primary headache is that it does not indicate an organic or structural cause. According to this classification, headaches can only be vascular, myogenic, cervicogenic, traction and inflammatory.
Management
Primary headache syndrome has many different treatment possibilities. In those who experience chronic headaches, the long-term use of opioids seems to result in greater harm than benefit.
Migraine
Migraines can be corrected with lifestyle changes, but most people need drugs to control their symptoms. Drugs can prevent migraines, or reduce symptoms once migraines begin.
Preventive drugs are generally recommended when people have more than four migraine attacks per month, headaches lasting longer than 12 hours or a very disabling headache. Possible therapies include beta blockers, antidepressants, anticonvulsants and NSAIDs. This type of preventive medicine is usually chosen based on other symptoms that the person has. For example, if the person is also depressed, antidepressants are a good choice.
Therapy that fails for migraine may be oral, if mild to moderate migraine, or may require stronger drugs given intravenously or intramuscularly. Mild to moderate headaches should first be treated with acetaminophen (paracetamol) or NSAIDs, such as ibuprofen. If accompanied by nausea or vomiting, antiemitics such as metoclopramide (Reglan) may be administered orally or rectally. Moderate to severe attacks should be treated first with an oral triptant, a drug that mimics serotonin (agonist) and causes mild vasoconstriction. If accompanied by nausea and vomiting, parenteral (through the needle in the skin) triptans and antiemetics can be given.
Some complementary and alternative strategies may help to overcome migraines. The American Academy of Neurology guidelines for migraine treatment in 2000 stated that relaxation training, electromyographic feedback and cognitive behavioral therapy may be considered for migraine treatment, along with drugs.
Type-tension headache
Tension-type headaches can usually be managed with NSAIDs (ibuprofen, naproxen, aspirin), or acetaminophen. Triptans does not help in tension-type headache unless the person also has migraines. For chronic tension type headaches, amitriptyline is the only proven remedy that can help. Amitriptyline is a drug that treats depression and also independently treats pain. It works by blocking the reuptake of serotonin and norepinephrine, and also reduces muscle softness by a separate mechanism. Studies that evaluate acupuncture for tension-type headaches have been mixed. Overall, they suggest that acupuncture may not be helpful for tension-type headache.
Cluster headache
Abortive therapy for cluster headaches including subcutaneous sumatriptan (injected under the skin) and triptane nasal sprays. High-flow oxygen therapy also helps with relief.
For people with extended periods of cluster headaches, preventive therapy may be necessary. Verapamil is recommended as first-line treatment. Lithium can also be useful. For people with shorter attacks, short-term prednisone (10 days) may be helpful. Ergotamine is useful if given 1-2 hours before the attack. See cluster headache for more information.
Secondary headache
The treatment of secondary headaches involves treatment of the underlying cause. For example, someone with meningitis will need antibiotics. A person with a brain tumor may require surgery, chemotherapy or brain radiation.
Neuromodulation
Peripheral neuromodulation has temporary benefits in primary headache including cluster headache and chronic migraine. How it works may still be researched.
Epidemiology
Approximately 64-77% of people experience headaches at some point in their lives. During each year, on average, 46-53% of people experience headaches. Most of these headaches are harmless. Only about 1-5% of people looking for emergency treatment because of headaches have a serious underlying cause.
Over 90% of headaches are primary headaches. Most of these primary headaches are tension headaches. Most people with tension headaches have "episodic" tension headaches coming and going. Only 3.3% of adults have chronic tension headaches, with headaches for more than 15 days in a month.
Approximately 12-18% of people in the world have migraines. More women than men have migraines. In Europe and North America, 5-9% of men experience migraines, while 12-25% of women experience migraines.
Cluster headaches are very rare. They affect only 1-3 per thousand people in the world. Cluster headaches affect about three times as many men as women.
History
The first recorded classification system was published by Aretaeus of Cappadocia, an ancient Greco-Roman medical scholar. He made the distinction between three types of headaches: i) cephalalgia, where he showed a short, light headache; ii) cephalea, referring to a type of chronic headache; and iii) heterocrania, paroxysmal headaches on one side of the head. Another classification system similar to the modern one was published by Thomas Willis, at De Cephalalgia in 1672. In 1787 Christian Baur generally shared headaches of being idiopathic (primary headache) and symptoms (secondary ones), and defined 84 categories.
Children
In general, children suffer from the same type of headache as adults, but the symptoms may be slightly different. The diagnostic approach to headaches in children is similar to that of adults. However, young children may not be able to express pain well. If a young child is fussy, they may have headaches.
Approximately 1% of Emergency Department visits for children is for headaches. Most of these headaches are harmless. The most common type of headache seen in the pediatric Emergency Room is the headache caused by the flu (28.5%). Other headaches diagnosed in the Emergency Department include post-traumatic headache (20%), ventriculoperitoneal shunt-related headaches (tools inserted into the brain to remove excessive CSF and reduce pressure in the brain) (11.5% ) and migraine (8.5%). The most common serious headaches found in children include cerebral hemorrhage (subdural hematoma, epidural hematoma), cerebral abscess, meningitis and ventriculoperitoneal shunt malfunction. Only 4-6.9% of children who have headaches have serious causes.
Just as in adults, most headaches are benign, but when headaches are accompanied by other symptoms such as speech problems, muscle weakness, and vision loss, more serious causes may be present: hydrocephalus, meningitis, encephalitis, abscesses, bleeding, tumors, blood clots, or head trauma. In this case, the evaluation of a headache may include a CT scan or MRI to look for possible structural disturbances of the central nervous system. If a child with recurrent headaches has a normal physical examination, neuroimaging is not recommended. Guidelines state children with abnormal neurologic examinations, confusion, seizures and new onset of the worst headaches in life, change of headache type or anything suggesting a neurological problem should accept neuroimaging.
When children complain of headaches, many parents worry about brain tumors. Generally, headaches caused by brain mass can not afford and accompanied by vomiting. One study found characteristics associated with brain tumors in children were: headache for more than 6 months, headache associated with sleep, vomiting, confusion, no visual symptoms, no family migraine history and abnormal neurological examination.
Some steps can help prevent headaches in children. Drink plenty of water throughout the day, avoiding caffeine, getting enough sleep and regular, eating a well-balanced meal at the right time, and reducing stress and overloading can prevent headaches. Treatment for children is similar to adults, but certain drugs such as narcotics should not be given to children.
Children who experience headaches may not necessarily have headaches as adults. In one study of 100 children with headaches, eight years later 44% of those with tension headaches and 28% of those with migraines were free of headaches. In another study of people with chronic headaches every day, 75% did not experience chronic headaches two years later, and 88% did not experience chronic headaches every day eight years later.
References
External links
- Headache in Curlie (based on DMOZ)
Source of the article : Wikipedia
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