Headache

By | May 14, 2012

Headache which is not due to intracranial or systemic pathology is described as primary headache. Primary headaches are appropriately treated in the pain clinic, whereas secondary headaches require investigation. Diagnosis is made by history. Examination and investigations may be necessary to exclude secondary headache. Diagnostic criteria have been defined by the Headache Classification Committee of the International Headache Society.

Migraine

Cluster headache

This condition is otherwise known as migrainous neuralgia or Horton’s syndrome.

Diagnostic criteria

Pain is described as severe unilateral orbital, supraorbital or temporal pain lasting 15-180 min, every other day or up to eight times a day accompanied by at least one of the following, on the same side as the pain:

• Conjunctival injection.

• Lacrimation.

• Nasal congestion.

• Rhinorrhoea.

• Forehead and facial sweating.

• Miosis.

• Ptosis.

• Eyelid oedema.

History, examination and investigation must exclude another disorder which might account for the pain, or if such a disorder is present cluster headache should not occur for the first time in close temporal relation to the disorder. It is a disease found more commonly in men, in the fourth decade of life. Attacks occur in ‘clusters’ lasting 4-10 weeks. Most commonly they happen two or three times a day. Bouts of headaches often occur in early spring or early autumn. Clusters are interspersed by pain-free periods of months to years, but rarely more than two years.

Headaches usually last about 45 min. They can occur at any time of day but typically start soon after the onset of sleep. The pain is burning in character. Classically sufferers have deep nasolabial folds andpeau d’orange skin changes. Precipitating factors include alcohol and altitude.

Cluster headache is thought to have a vascular mechanism.

Management

Intranasal capsaicin has been shown to reduce headache severity. Sumatriptan has been shown to be effective. Other treatments for which benefit is claimed are:

• Abstinence from alcohol.

• Ergotamine 1-2 mg p.r. before the attack.

Methysergide 2 mg t.d.s.

Verapamil 40-80 mg t.d.s.

• Oxygen for 15 minutes during the attack.

• Sphenopalatine local anaesthetic block.

• Sphenopalatine ganglion radiofrequency lesions.

• Partial trigeminal nerve ablation.

Tension headache

Diagnostic criteria

The criteria for tension headache are the presence of at least ten previous headache episodes with frequency less than 180 headaches per year or 15 per month. The headache can last up to 7 days and should be accompanied by at least two of the following features:

• Pressing, tightening, non-pulsating.

• Mild or moderate.

• Bilateral.

• No aggravation by routine physical activity.

Nausea and vomiting are not features and photophobia and phonophobia should not be present together.

History, examination and investigation must exclude another disorder which might account for pain, or if such a disorder is present tension headache must not occur for the first time in close temporal relation to the disorder.

Headaches usually occur daily. There is a history of stress, and depression may coexist. It is more common in women. Overuse of analgesics may aggravate. Examination may reveal tender points.

Management

Depression should be treated if present. Small doses of tricyclic antidepressants are also effective in those without clear signs of depression. The benefit of relaxation and cognitive strategies are claimed and nonsteroidal anti-inflammatory drugs (NSAIDs) are similarly said to be effective.

Chronic paroxysmal hemicrania

This has the same features as cluster headache but attacks occur 15-20 times a day and last 3-15 minutes. It is more common in women and does not follow the onset of sleep.

Treatment

Indomethacin 75-150 mg orally has been said to be effective.

Cervicogenic headache

This is headache which originates in the structures in the neck. Pain from one or both sides of the neck radiates to the occiput, temples or frontal area. It is a dull pain, worse in the morning and exacerbated by movement or tension. Lateral flexion and rotational movements are restricted. Headache is often due to irritation of the C2 and C3 nerve roots and the greater occipital nerve.

Management

Steroid injections to cervical facet joints give temporary relief in 60-70%. Benefits have also been claimed for greater occipital nerve blocks, transcutaneous electrical nerve stimulation (TENS), acupuncture and physiotherapy.

Occipital neuralgia

This is a paroxysmal jabbing pain in the distribution of the greater or lesser occipital nerves. Aching can persist between paroxysms and there may be altered sensation. The affected nerve is tender to palpation.

The pain is eased temporarily by local anaesthetic block of the appropriate nerve. Subsequent injections of steroid are said to be effective.

Analgesic headache

Large daily doses of aspirin, paracetamol or weak opioids taken for the treatment of headache can aggravate headache. The daily use of ergotamine for headache or sudden withdrawal from ergotamine induces headache. The withdrawal headache is thought to be due to vasodilatory counteracting mechanisms which have developed during the use of the drug but are left unopposed when the drug is withdrawn. Sumatriptan, used for the treatment of migraine causes the same problems.

Management

Recommendations for prevention are:

• Analgesics should not be taken every day for the treatment of headaches.

• Ergotamine should not be taken more than 10 times a month.

• There should be restrictions on the use of all triptan type of drugs, such as sumatriptan, to approximately 10 times a month.

• Opioid drugs should not be used for the treatment of headache.

Idiopathic stabbing headache

This is stabbing pain, predominantly in the distribution of the first division of the trigeminal nerve. It lasts for a fraction of a second. It occurs as a single stab or a series of stabs, at irregular intervals.

Management

Indomethacin 25 mg t.d.s. is used to treat.

Miscellaneous headaches

A number of primary headaches do not fit into these specific categories, such as those provoked by physical exertion, sexual activity, certain foods, very cold foods, coughing or restricting devices worn on the head. Avoidance of provoking factors should be advised where possible.