Headache
[abbreviated ‘ha’]- NOTE: only muscles and arteries cause pain
Headaches – primary [tension, migraine, cluster],
secondary [brain tumor, etc.]
99% of women and 93% of men get headaches (Silberstein, Hospital Medicine / January
1994)
Things to remember in history: Duration: acute
[never had before], transient or recurring [tension, migraine, cluster,
hypertension]
Onset: rapid [tumor, aneurysm, migraine, cluster, glaucoma, etc.] gradual [tension, ophthalmic, etc. ]
Age: kids, young adult- migraine
older-may be organic
[cervical OA, tumor, hypertension, etc.]
Any age-tension headaches
Location: unilateral,
bilateral or shifting- indicative but not totally reliable.
Character and severity: thunderclap onset- subarachnoid hemorrhage
Severe and pulsating [throbbing]- migraine
Deep
and boring-cluster
Dull,
nagging and persistent- tension
Tight band- hypertension
Throbbing or agonizing-
migraine, sinus, cluster, tumor, tension, meningitis, abscess
Ache- migraine, sinus,
tumor, meningitis, concussion, ophthalmic, OA, muscle tension, abscess,
etc.
Course: progressively
worsening- organic
No change but long term-
MORE LIKELY to be benign
Prodrome and aura- mood changes, food cravings 1 or 2 days before classic migraine
Frequency: daily
several times a year
several times in a week and
then not for a year
Family history: especially with migraines
Local or systemic causes:
any disorder or almost any
tissue or function of the body may be at fault
Aggravating factors:
exercise aggravates: any
vascular headache [meningitis, migraine, encephalitis, etc.]
Photophobia and phonophobia are often present with both migraine and tension headaches.
Alcohol
may precipitate cluster.
Other: pain changes with posture
associated symptoms [nausea,
etc.]
relief or no relief with
analgesics
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Analgesics [with/ without
barbituates or sedatives] if taken more than 3x/wk or ergotamine 2x/wk
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Mobilization of the Cervical Spine in Chronic
Headaches get the concept
Manual Medicine ’87 3:15-17
Greater than 40% of the headaches studied were due
to degenerative processes of the cervical spine
If these are due to degenerative process they occur
typically in second half of life. They
demonstrate head pain with neck and upper extremity pain most often in morning,
lasting several hours, if a stronger degenerative process – pain may also occur
in PM and there may be an increase pain with decrease in activity.
75 of 100 cases were alleviated immediately upon
manipulation.
56/100 decreased symptoms after 3 tx. in one week,
75/100 decreased after 9 tx.
In the 6 month follow up- 25% no headaches, 40%
improved but still took Rx, 35% improved for one month only.
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Cervicogenic headache- pain of either the greater or
lesser occipital nerve
Greater occ nerve [dorsal ramus C2] – sensation
middle post of scalp
Lesser occ, nerve:
Ventral ramus of C2 to head and face [pain] joins with C3
– this path is vulnerable to
compression and traction –-
it runs in the retroauricular
and postero-lateral aspects of the head and
passes over levator scap. and splenius cap. Ms.
Between the trap and the SCM.
It pierces the fascia near its cranial attachment and can anastomosis with branches of
the greater occipital nerve.
Roots of C2 connected to the posterior atlanto-axial
membrane:
The dorsal branch emerges posteriorly between the
posterior arch of C2 and the obliques capitis inferior.
The ventral branch of C2 crosses C1/C2 capsule and
attaches to the fascia of the obliq. cap. Inf.
Therefore, it covers the superior segment of the
vertebral artery and attaches to the levator scap and/or the middle scalene
under the SCM then one branch goes over
the post lat. mastoid and the other to the medial head.
Aggravation/Symptoms: active or passive movement of the neck, may be accompanied by
crepitus, associated with decrease Occ/C1 motion and a decrease in pain with
anesthetic block on the side of pain at C2
1.
Forceful movement of the
levator scap. Stretches the ventral ramus of C2 [nociceptive]
2.
Vascular compression by the
vertebral artery of the C2 root leading to pain in the face
3.
Pain fibers from the spinal
tract of the trigeminal nerve join the first four cervical nerve roots
therefore you have the propagation of sensation from the cervical spine to the
trigeminal dermatomes
i.e.: superior cervical ganglion to the cervico-gasserian anastomosis to the ophthalmic branch of the trigeminal nerve leading to fronto-occipital pain
Lesser occipital nerve [ventral ramus of C2 which
joins C3] refers pain to the forehead, orbits and face due to the intermingling
through the spinal nucleus of the trigeminal nerve in the lower medulla and
upper cervical cord [concept:
area of referral and lesser occipital nerve with trigeminal and C3]- vulnerable
to compression and traction postauricular and postero-lateral aspects of the
head as it passes over the levator scap
and splenius capitus muscles and between the trap and SCM]- (Lesser
Occipital Nerve and Cervicogenic Headache
Clinical Anatomy 7:90-96 [94]) It then joins the greater occipital nerve. The dorsal root of C2 is connected to the
posterior atlanto-axial membrane and emerges posterior between the arch of C2
and the inf. Capitus obliq. therefore tension in the muscle can cause headache
or referred pain. The ventral branch of
C2 crosses C1/2 capsule and attaches to the fascia of the inf. oblique muscle
therefore the nerve covers the superior segment of the vertebral artery and
attaches to the levator scap. and/or the middle scalene under the SCM then one
branch goes over the posterior lateral mastoid process and the other to the
medial head.
Cervical roots refer to forehead, orbits, face due
to intermingling of the afferent superior cervical roots through the spinal
nucleus of the trigeminal nerve in the lower medulla and upper cervical cord.
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mechanisms of etiology of headaches
¨ muscle contraction 90%-
cervico/occipital, anxiety, depression, posture
¨ traction/inflammation 2%-
diseases of the eye & nose, teeth/throat, masses, neuralgias, arteritis,
TMJ, infections, allergy, cervical OA, chronic myositis [traction- on veins and displacement of
venous sinuses, distention of meningeal arteries at the base of the brain]
¨ vascular 8%- migraine, cluster, ocular, toxic,
hypertensive,
with cluster, migraine and
hypertension-feel more relief sitting upright
with sinus and tension- more
relief lying down
¨ Referred pain
headaches: due to altered vascular tone
in dural arteries, venous sinuses and arteries at the base of the brain
usually present with photophobia and sensitivity to sound
[caution: migraines and
cluster can too!] includes cranial mass.
These are also due to Vit. B
loss in hangovers from transient demyelination with resultant hypersensitivity.
1. Cranial mass: due to primary or secondary neoplasm, expanding
aneurysm, subdural or epidural hematoma, brain abscess, etc.
Severe aching pain, typically unilateral and over
site of tumor, often worse in AM, occasional remission in pain may occur
Progressive unilateral weakness, projectile
vomiting, papilledema. See neoplasm and
brain tumor picture/descriptions.
Abnormal EEG, malaise, behavioral and mental
changes, seizures, neurologic deficits, possible weight loss [due to long term
depression]
Not a pathagnomonic pattern [remember: chronic headaches for years typically rules
out mass]
The increased intracranial pressure from the mass
stretches the meninges and vascular structures causing pain, most likely, in
the area of the mass. It is aggravated
by anything that increases intracranial pressure [Desjerine’s Triad, lifting,
bending over, etc.]
Brain tumor: 50% of brain tumors have
headaches. Pain, early on, is due to
the distortion of the pain-sensitive structures not the increase in
intracranial pressure. progressive yet
intermittent pain that is localized but can be general. Severity is variable. Possible neuro findings: vomiting,
progressive unilateral weakness, changes in mood and personality, aphasia,
visual changes [papilledema and vision changes], paralysis. Look for tumor or abscess if skull is
tender. Aggravated by coughing,
sneezing, straining at the stool, bending over.
Neoplasm of the skull: localized typically. Often tender over the area. Steady by variable severity of pain. Watch history and cranial nerves.
Traction hematoma: headache develops after significant time lapse after head trauma-
days, weeks, months- watch for it in whiplash
There is an accumulation of blood in the subdural
space requiring surgery.
The progression, timing and attributes of pain
[localized, etc.] are similar to those of a brain tumor as the blood is
occupying space.
Early: no
physical signs Late: localizing signs of lesion with frequent
episodes of drowsiness, mental confusion or coma
Radiographs of the skull may demonstrate a shift in
the pineal body
Cerebral hemorrhage: sudden generalized headache
with cerebral disturbances associated with the site of the bleed
Half of those with hemorrhage have sudden onset of
severe generalized pain
Frequently the patient vomits ONCE. Seizure or coma may occur.
Cerebellar hemorrhage: develops slowly, repeated
vomiting occurs, headache is occipital, vertigo and paralysis of the conjugate
later gaze and other ocular disorders occurs.
Thalamic hemorrhage: hemiplegia, dysphasia,
homonymous hemianopsia, extraocular paralysis
Subarachnoid hemorrhage: excruciating generalize
headache with nuchal rigidity- thunderclap onset. May begin as localized and then become generalized. Due to aneurysm or angioma.
Pain tends to recur at the same time each day, may
last for hours to days, and may find hyperesthesia over the involved sinus
2. Eyestrain: pain in orbits that radiates toward the occipital region
following the distribution of the ophthalmic division of the trigeminal
nerve Often begins at the end of the
day.
Pain does not necessarily subside immediately with
rest. Due to sustained contraction of
intraocular and extraocular muscles [refraction
/accommodation].
Note: pain from glaucoma is a
sharp ache and most intense around the orbital rim. Rule out increased intraocular pressure, refractive errors, and
fixation of the iris.
-ocular: due
to an increase in intraocular pressure- as in glaucoma, uveitis
sharp pain, photophobia is frequent. Pain may radiate from the eye to the occiput
3. Hypertension Headache: generally throbbing
occipital or vertex HA, paroxysmal.
According to some sources, this is common in those with diastolic
pressure over 120. Occurs in cardiac
and renal insufficiency. Feels
band-like, may be bilateral, paroxysmal, generalized throbbing in the occiput
or vertex. It is usually worse on
awakening but remains throughout the day.
According to other sources, this may be due to low blood pressure, uni-
or bilateral. Digital compression of
the external carotid, frontal, supraorbital, postauricular or occipital arteries
abolishes the headache.
Note:
ergotamine [migraine Rx] is also used for this as it increases
peripheral arterial tension.
4. Hypoglycemia: occurs 3 hours after eating, disappears on eating. Associated with dizziness, fatigue,
hyperhidrosis, irritability, trembling, weakness.
5. Cranial Concussion: momentary compression of
cranial capillary with ischemia/anemia.
Immediate impairment of neural function that is
usually transient. The disturbances of
consciousness include: memory faults,
visual disorder or equilibrium, possible amnesia. A headache may the only complaint and the intensity can be widely
varied. If vertigo is present, it is
positional. Shallow breathing, pallor,
feeble pulse, and hyporeflexia may occur.
If prolonged unconsciousness occur you will see pupil inequality.
Dementia pugilistica [punch-drunk syndrome]:
recurrent mild traumas: dull expression, slurred speech, tremor, slow movements
and mentality.
Post-trauma headache: A dull, often poorly described, generalized headache. It is often accompanied by dizziness,
giddiness and emotional instability.
Usually after a concussion rather that after focal brain damage. This tends to dissipate within 6 months in
75% of patients and 2 years in 95%.
6. Migraine, Tension, and Cluster
Headaches-there
are certain similarities and differences
Migraine:
More women than men. Thought to
be a recessive gene with 70% realization.
Has often begin in childhood and end in the 50s, or they might not begin
until the 50s. [FYI: acetaminophen usually helps in children but
not adults.] There is a higher than
normal incidence of allergy. Any
migraine that is progressive in spectra or visual auras, especially with
seizures or neurologic signs that are transient, may be due to arteriovenous
malformation. This is often the case in
those 10-30 years old.
–onset usually in the eye
area with uni- or bilateral spread. Possibly nausea and
vomiting. Vomiting may end the headache
and so might a nap or night’s sleep.
Precipitating factors: Sudden change in stress
levels. Too little or too much sleep
may precipitate an episode. Tyramines
may trigger these: cheese, chocolate,
red wine, and more.
Ø 2 types – classic [with
aura] and common [without aura]
Ø subtype – status migrainosus
– one episode lasts longer than 72 hours
sometimes assoc. with
vomiting that may lead to state of dehydration [hospitalization]
Ø recurrent episodes, each 4
to 24 hours
Ø auras – abnormal sensation
that precede headache by 15 to 30 min.- visual disturbance, olfactory, etc.
visual disturbance,
scintillating, negatives, unilateral
paresthesia and/or numbness, sometimes unilateral weakness
-
due
to vasoconstriction [seen with retinal vascular constriction]
-
visual
aura is usually unilateral-
-
homonymous
-
scintillating
scotoma: black & white wavy lines [like shimmering off the pavement]
-
fortification
spectrum: zigzag colored patterns with
dark centers moving across the field of vision
-
other
variants
-
ophthalmic
scotoma: momentary blindness in the
entire visual field, or the upper/lower/bitemporal fields or homonymous
hemianopsia
-
opthalmoplegic
migraine: transient unilateral
paralysis of the 3rd cranial nerve producing lateral deviation and
palpebral ptosis that can last a week or more, similar presentation to that of
a leaking aneurysm from the Circle of Willis or a lesion of the cavernous sinus
severe pain over one eye,
sometimes followed by double vision.
Scintillating scotoma:
colored flashes with radiation outward from the center of a homonymous field
defect. Within 5-15 minutes, these
flashes reach the periphery of the field, leaving a transient central
scotoma. Could also have a horizontal
scotoma.
-
hemiplegic
migraine: paralysis for a few minutes to two to three days; even neurologists
will rule out cerebral disorders with EEG, etc.
-
Dysphasic
migraine: unilateral paresthesia or anesthesia in the face, arm or foot. If the right side is involved then dysphasia
and homonymous hemianopsia may occur.
Ø initiated by prodome –some
lethargy or depressed or excited and/or anxious for hours to days
Ø prodrome can also be food
cravings for a day or two prior to onset.
Check history.
Ø pain-usually unilateral,
sometimes bilateral, moderate to severe, typically throbbing
Ø Often photophobic,
phonophobic, nauseated and sensitive to movement, ataxic, dysphasic, syncopic
Ø Patient takes passive
posture to find relief
Ø Attacks may occur in groups
like cluster headaches
Ø May have some features of
cluster – red eyes, etc.
Ø Some attacks may begin in
frontal area, others in the post. –
Whole brain affected but it manifests as focal pain
- affected nerves are related to the trigeminal nerve and the c/s ms by the
cervical cord [descending tract of trigeminal –to C2] Study, Silberstein, the
proximal middle cerebral artery was stimulated in a cat. This stimulated the ipsilateral trigeminal
ganglion then bilateral in the sup cervical gang leading to bilateral neck
pain.
Ø Contraction of the scalp
muscles, especially the temporalis, and the back of the neck on the affected
side
Note: Neck
stiffness or pain are not reliable harbingers
Acupuncture/ PT, exercise may reduce attack
frequency, abbreviate the onset or bring one on
Ø Therapeutics to calm tender
muscles in the neck may prevent onset
Ø IF AURA PERSISTS AFTER THE
HEADACHE IS OVER…LOOK FOR OTHER PROBLEMS.
Ø They like dark quiet rooms,
and will be still whereas the patient with the cluster HA will pace.
Ø Breathing into a paperbag to
increase carbon dioxide may decrease vasodilatation.
Ø most common, typically bilateral, pressing or band-like, mild to moderate
intensity, not aggravated by exertion
Ø lasts 30 minutes to seven
days or even weeks
Ø DULL, NAGGING AND PERSISTENT
Ø associated symptoms absent
or mild --but may include: anorexia, photophobia, phonophobia, pericranial
muscle tenderness
Ø teeth grinding and neck
tenderness frequently associated
Ø can occur at any age
Ø fronto-occipital, generalized, or bandlike: occipital aching or stiffness, with aggravation by neck motion or
postural strain but general exercise does not aggravate. Tenderness of the posterior cervical muscles
and traps is often noted. Monitor the
tension of the SCM and scalene muscles.
Both can:
Non-throbbing, moderate intensity, anorexia, photophobia, phonophobia,
these can change sides with each episode
-There is not a consistent finding of loss of
cervical range of motion or particular muscle hypertonicity with either of
these.
But migraine may:
nausea, vomiting and diarrhea, aggravated by movement, unilateral or
bilateral pain, severe
Typically men, unilateral, ABRUPT ONSET,
excruciating pain, unilateral, DEEP AND BORING, often precipitated by alcohol
ingestion.
30 to 90 minute episodes, 1 – 6 times per day,
recurrent episodes occur in clusters of time for weeks or months, often
awakened at night with them
Assoc. with ipsilateral autonomic symptoms: nasal stuffiness, lacrimation, redness of
the eye, flushing of the face
no prodome or aura or GI symptoms, intense stabbing
pain, patient paces or bangs head during attack to find relief. Inhalation of 100% oxygen often relieves.
Flushing [vasodilatation] noted on involved side
with lacrimation, runny nose, injected eye.
The pupil may be constricted on that side with conjunctival congestion.
7.
Psychogenic: Variable pattern. The
patient cannot reliably tell you where the pain is or the pain moves from site
to site. It may be recurrent/constant,
varying in severity, and/or location. It is typically exacerbated by anxiety
&/or conflict. Watch for fight or
flight signs: sweating, increased
pulse/systolic blood pressure, hyperreflexia or they may be normal.
8.
Meningitis, Acute: Head pain with radiation to the neck. Head pain is constant and severe. Meningeal signs [stiff neck (even nuchal rigidity), Kernig’s
sign] with fever and vomiting are often associated. Patient is very ill and is not AOx3 [may be diagnosed as
psychotic- mistakenly]. Often recent
history of upper respiratory infection or pharyngitis.
9.
Meningitis, Chronic: Generalized vertex headache.
Headache and fever less intense than in acute but still moderate to
serve. Meningeal signs may be found and
the sensorium may be clouded. Cranial
nerve palsies may be present.
10.
Otic: temporal or around the ear and unilateral. Due to otitis media externa/media or malignant
otitis media or myofascitis. May be
associated with decreased hearing acuity, fullness, discharge, tinnitus. Pain may be throbbing or piercing. May also be associated with neural
sensitivity to cold.
11.
Paranasal sinus: usually bilateral, mild to severe, remember locations of referred
pain. Posture changes may
aggravate. Often worse in the morning
upon awakening. Cold may aggravate as
well as changes in barometric pressure.
12.
Occipital
headaches: due to muscle
tension, sphenoid sinusitis, subluxation, vertebrobasilar disorders, migraine
[initially].
Watch all patients with long-standing pain due to
the possible development of depression and cognitive dysfunction: from long-standing pain
13.
Myofascitis
and headaches: Travell Vol. I
Suboccipital Muscles: Rectus Capitis Posterior Major and Minor, Superior and Inferior
Oblique
Their action is rotation is rotation, lateral
flexion and extension of the head on the same side; and are stessed by the
restraint exerted by head during long
term head flexion, rotation and lateral flexion on the opposite side.. They overly a portion of the vertebral
artery [causing possible compression].
They may only be tender and not display typical trigger point signs but
will demonstrate restriction in normal motion.
Trigger points
in these muscles cause ill-defined deep pain that radiates from the
occiput to the eye .
Splenius Capitis and Splenius cervicis: ache INSIDE the head
Splenius cervicis:
pain straight through the head pain from the occiput to the back of the
eye and even to the neck and shoulder
splenius capitus : vertex pain
They run from the thoracic and lower cervical
spinouses and tvps of the upper cervicals.
Their action is cervical extension and rotation to the same side. Homoloateral blurring of vision may
occur. Due to trauma, and prolonged
forward flexion and obtuse postures.
Aggravated by fatigue, and cold drafts.
Postural stresses like anterior cervical with bearing with extension
secondary to thoracic kyphosis, playing guitar, watching a game through
binoculars while sitting in a slouch or even glare from glasses [adjusting the
head to accommodate new bifocals, etc.]
The patient will have restricted and painful rotation on the side of
involvement [look at levator scap, too].
Posterior Cervical Muscles: Semispinalis Capitis and Cervicis and
Multifidi: pain at C4/5 up to occiput
and down to neck and trap region. A bandlike
pain may radiate from the occiput to the orbit. Decreased motion of cervical flexion and some decrease in extension
and rotation. Numbness and tingling
over the scalp over the occiput on the involved side may occur. Aggravating factors: reading, etc. in poor
posture and even glasses set at the wrong angle to the face, eyestrain,
ergonomic issues, kyphosis [primary or secondary], depression. The se can also be causative factors as well
as trauma. The greater occipital and
can have pain in the eye. Due to
chronic stress of the SCM
SCM:
Sternal portion: pain to the occiput, vertex, around
the eye and frontal/maxillary sinuses or perhaps down to the sternum
Autonomic symptoms on the side of involvement may
include: lacrimation, injection, ptosis [from spasm of the orbicularis oculi]
and not weakness of the levator palpebrae], visual disturbances [blurring,
dimming of light intensity], maxillary sinus congestion. tinnitus and possibly
trouble hearing.
Clavicular portion: the ear and postauricular areas,
both frontal sinuses, possibly the cheek and molars on that side,
proprioceptive dysfunction [disagreeable movement or sensation inside the
head], syncope may follow quick head turns.
Episodes of vertigo may last seconds to hours by changing position from
a sudden stretch of the SCM. Sudden
falls when bending, ataxia [veering to one side with the eyes open. May be aggravated when looking up, may feel
like they are going to fall over backward and when looking down, they feel that
they may fall forward. Nausea is
common. Dramamine relieves nausea but
not the dizziness. Often involved with
the trap. Dysmetria demonstrated if two
equally weighted objects are placed in outstretched hands, the one on the
involved side will be underestimated in weight.
Autonomic reaction of sweating and vasoconstriction
to the frontal area of referred pain.
The muscles are involved with C2 and C3.
Neck pain is not a common symptom but the patient
may feel soreness. Often involved in
tension headache. Ipsilateral sweating
of the forehead, injection, ptosis, lacrimation, rhinitis, blurring or double
vision.