Headache

Headache is the most common types of pain in the community.

Classification of headace:

  • Primary headaches

  • Migraine,

  • Tension-type headache

  • Cluster headache and other trigeminal autonomic headaches

  • Other primary headaches

  • Secondary headaches (due to trauma or other system diseases,       headaches)

  • Cranial neuralgia, central and primary facial pain and other    headaches

  • Cranial neuralgia and Central causes of facial pain

  • Other headache, cranial neuralgia, central or primary facial pain

 

PRIMARY HEADACHES

Primer headaches are headaches that occur without being associated with central nervous system or other system diseases.

Primary headache accounts for over 90% of headache patients.

 

Migraine:

  • Migraine headache occur in attacks and may last between 4-72 hours in adults.

  • It is generally localised on one half of the head, however it can occur on both sides. Pain

  • the pain generally beginsand spreads around the neck or around the eye. It is often described as throbbing.

  • This could be moderate or severe and physical activities can increase the severity.

  • Restricts the person's daily activities.

  • Along side nausea and/or vomiting light, sound and smell discomforts the patient.

  • 80-85% of migraine headaches are without aura and 10-15% are with aura

 

  • Prior aura headache attacks (rarely before or after pain) which gradually increases (5-20minutes) and goes away in less than 60 minutes is refered a focal neurologic symptoms.

 

  • Aura symptoms are visual, sensory, motor, language, and the brain stem disorder.

  • Prodrom (prior) or Postdrom (after) migraine attacks behaviour and mood changes could be seen.

 

Apart from auraless and auroral migraines, there are also more rare migraine types, such as childhood periodic syndromes, migraine predisposing factors, retinal migraine and migraine complications.

 

 

Tension type headache

  • The most common type of headache found in community.

  • Pain is commonly found in the bilateral occipital or frontal region, sometimes embraces the head.

  • It can be blunt, constrictive, mild or moderate

  • Does not prevent physical and daily activity

  • Nausea and vomiting are  often not accompanied

  • Symptoms such as photophobia or phonophobia may accompany.

  • Rare episodic (less than 1 day per month),

  • Frequent episodic (less than 15 days per month, 30 minutes to 7 days of attacks

  • There are three types of headache-type; headache that is chronic (continuous or continuous for 15 days or more per month).

 

 

Cluster-type headache

  • The incident is found in 4% of the population, mainly in men.

  • There are two types of cluster headache (85%), chronic (15%) episodic and one month without pain (15%). These two forms can transform into each other,

  • Repeated 1 to 8 times a day, often awakened at night by pain.

  • In the same set period, pain is always localized around the same eye / orbital, supraorbital, and / or temporal region at all times and in other cluster periods.

  • The pain is very severe with burning sensation. Iasting an average of 1 hour (15-180 min).

  • Ipsilateral autonomic findings can be accompanied  (ipsilateral conjunctival hemorrhage and / or eyebrows, stinging in the eye - pricking sensation, nasal congestion and / or nasal discharge, eyelid swelling, forehead and face sweating, myosis and / or ptosis).

 

 

 

Paroxysmal hemicrania

  • Pain duration may be brief (2-30 min) and 5 or more days 30-40 / day per cluster head.

  • The characteristics of the pain are similar to those associated with symptoms of cluster headache

  • The characteristics of the pain are similar to those of the accompanying symptoms and the cluster headache.

  • More common among women

  • Responds very well to indomethacin therapy

  • There is also a chronic form of painless periods of more than one month.

 

 

Conjunctival redness, survival, short-term unilateral neuralgiform headache attacks (SUNCT - short lasting Unilateral Neuralgiform headache attacks with conjunctival injection and tearing)

 

  •  Trigemino-autonomic headaches are characterized by unilateral   pain attacks that are much shorter and more frequent than headaches.

  • The eye on the same side is accompanied by frequent eyebrows and stinging with redness.

  • Other rarely seen head primers:

  • The primer in this section should be assessed with imaging and other appropriate tests as headaches may be symptomatic.

 Primary cough headache:

  • Occurs in relation to coughing or exfoliation

  • It can suddenly start and pass in seconds, or can take up to 30 minutes.

  • It is usually bilateral and often affects people over 40 years old.

  • In the presence of long-term pain,pathology of the back pit or cranio-vertebral fusion should be investigated, especially before the age of 40.

 

 

Primary exercise headache:

  • Occurs only during or after physical activity.

  • Pulmonary function, usually limited to minutes (5 min-48 hr)

  • It gets more prominent features in hot environment and high places.

  • When first visible, subarachnoid hemorrhage and arterial dissection should be excluded.

 

 

Primary headache associated with sexual activity (pre-orgasmic and orgasm

  • Severe explosive (orgasmic headache) headache that is increasingly associated with sexual intercourse (preorgasmic headache) or suddenly developing during orgasm.

  • It is necessary to exclude situations such as subarachnoid hemorrhage and arterial dissection if it’s the first time

 

Hypnic headache: (sleeping headache) 

  • It is present during sleep and awakes the patient. Generally found in patients over 50.

  • Common or unilateral, mild or moderate, blunt and short lasting one hour (15-60 min).

  • Frequency is 15 times or more per month.

  • Autonomic symptoms do not accompany

  • Cerebral organic pathologies should be excluded

 

Primary thunderstorm or explosive headache: 

  • Acute, severe pain reaches the most severe level in less than a minute and may last from 1 hour to 10 days. Usually it is not repetitive, but it can be repetitive in the first week.

  • Primary thunder storm like headache is diagnosed but only when other organic causes are excluded.

 

 Hemicrania continua (Prolonged half-headache):

  • A persistent headache that starts after 50 years of age,localised in one part of the brain and does not change the localization. Moderate pain but does not have painless episodes.

  • There may be autonomic symptoms on the same side of the pain

  • It responds well to indometazine therapy.

 

 

 

 Headache due to substance abuse and withdrawal

  • The use of ergotamine, triptan, opioids, and combined medicines for    more than 10 days per month  and 15 days or more of simple analgesics per month may lead to chronic daily headache.

  • Patients should be warned in regards the frequency of pain reliever use should be reduced by controlling headaches with prophylactic treatment

  • Patients should be warned to reduce the use of painkillers when controlling headaches with prophylactic treatment

 

Trigeminal neuralgia (tic douloureux)

  • It is usually single sided and has three branches of the fifth nerve, especially the second and third branches.

 

  • There are trigger points on the face and the chin can be stimulated by speech, chewing, washing the face, brushing the teeth, shaving, facial movements and cold air.

 

  • Spontaneous improvement is observed in at least 6 months in approximately 50%.

 

 Secondary headaches

Secondary headaches are headaches associated with diseases that involve the nervous system or other systems.There are no specific types of secondary headaches, they can mimic any type of primary headache.

In secondary headaches; there is evidence of a demonstrable causal emerging in a close temporal relationship

The headache is greatly reduced or passed within 3 months (which may be shorter in some diseases) after successful treatment of the underlying disorder. Progressive events, such as brain tumors, may not be successful within 3 months despite successful or unsuccessful treatment.

 

 

Features that suggest secondary headache in story:

  • Headaches starting before the age of 10, after the age of 50

  • Starting in the last 6 months or not changing its characteristics such as character, frequency and intensity.

  • Progressing within days and not responding to treatment.

  • The acute and severe nature of a new headache.

  • Defining as the "most severe pain" in the person's life.

  • Emerging during pregnancy or postpartum.

  • Increased physical activity, impingement or coughing.

  • In association with body and head position.

  • Age at onset and clinical features not typical of defined headache.

  • Progressive and untreatable vomiting.

 

 

Patient's examination:

  • Fever, stiff neck

  • Presence of epileptic seizures.

  • Focal neurologic findings.

  • ( hyaloid haemorrhage) Consciousness disorders or syncope.

  • Findings of the eye (papilloma, sub).

  • Weakness, weight loss, and the presence of systemic disease.

  • If there is a disease causing sleep disturbance, secondary headache should be considered.

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Prof. Dr. Altan Şahin, 2018