Headache is one of the commonest symptoms of medicine. In addition to the long list of medical causes, there is wide range of ear, nose and throat diseases that can cause headache.
Definition:
Headache refers to the pain or discomfort between the orbits and occiput and arises from pain-sensitive structures.
Etiology
Headache can arise from —-
- Psychological,
- Otolaryngological (Nose and paranasal sinuses related),
- Ophthalmological (Eye related),
- Neurological,
- Dental and
- Systemic diseases.
Tension type headache is most common.
Some of the common causes are as follows:
1. Raised intracranial tension
a. Space occupying lesions:
Cerebellopontine angles (CPA) tumors such as —-
- Acoustic neuroma,
- Pituitary tumors,
- Otogenic brain abscesses (cerebellar and temporal lobe).
b. Infections:
Encephalitis and meningitis caused by suppurative otitis media and sinusitis.
c. Intracranial venous sinuses:
Otogenic sigmoid sinus thrombophlebitis and rhinogenic cavernous sinus thrombophlebitis block the outflow of intracranial venous blood.
d. Hypertension: Severe arterial hypertension.
2. Intracranial aneurysms:
They can put pressure and involve cranial nerves.
Rupture will result in subarachnoid hemorrhage.
3. Migraine
4. Temporalis muscle:
a. Grinding teeth at night
b. Impacted wisdom teeth
c. High bite
d. Temporomandibular joint disorders
e. Clenching of jaws
5. Cervical spondylosis:
Prolapse of cervical intervertebral disc
6. Temporal arteritis
7. Tension headache:
Anxiety or depression symptoms are often present.
8. ENT causes:
a. Nose and paranasal sinuses: Rhinosinusitis, deviated nasal septum (touching middle turbinate), vacuum headache (negative pressure in sinuses) and tumors
b. Nasopharynx: Adenoiditis, infection, cysts and tumors
c. Oral cavity: Infections, ulcers and malignancy
d. Oropharynx: Peritonsillar abscess, parapharyngeal abscess, retropharyngeal abscess and tumors
e. Larynx and laryngopharynx: Malignant tumors
f. Ear: Intracranial complications of suppurative otitis media and tumors
9. General:
HEADACHE is common constitutional symptoms in cases of fevers
Headache in children: The commonest causes are FEBRILE ILLNESS and RHINOSINUSITIS.
In children with fever and neck stiffness, consider meningitis, encephalitis and cerebral abscess.
History and Examination
1. History:
Inquire about the following information —
a. First or the previous attacks.
b. Onset is acute or gradual (days or weeks).
c. Duration and frequency: Know whether chronic or recurrent.
d. Site of headache.
e. Accompanying features.
f. Factors: Aggravating, relieving and precipitating.
2. Examination:
In addition to the general and ENT head and neck examination one should perform ocular (acuity, tenderness, strabismus, tension, fundus), psychological and neurological examination.
3. Characteristic features of different headaches:
A. Migraine
B. Raised intracranial pressure:
The headache is generalized and aggravated by bending and coughing. Headache is worse in the morning on awakening. It may awaken the patient from sleep. The severity gradually progresses. In later stages, it is associated with vomiting and transient loss of vision with sudden change in posture.
C. Tension-type Headache
This is the most common type of primary headache. Exploration of the underlying cause of chronic anxiety is important.
Clinical features 0f TENSION-TYPE HEADACHE:
Headache is nonpulsatile, diffuse, dull, aching and band-like.
Headache is usually more in occipital and cervical region.
Patients often complain of poor concentration and other vague nonspecific symptoms.
Aggravating factors for TENSION-TYPE HEADACHE:
Headache is constant daily and may be exacerbated by emotional stress, fatigue, noise or glare.
It gets worse on touching scalp (pericranial tenderness).
Treatment 0f TENSION-TYPE HEADACHE: :
Antimigrainous agents are prescribed when simple analgesics are not effective.
- Relaxation techniques: The massage, hot baths and biofeedback are helpful.
- Botulinum toxin type A: Local injection may be useful.
D. Depression Headache
Clinical features of Depression Headache:
Headache is usually worse on arising in the morning.
Patients may have other symptoms of depression and somatic delusions.
Treatment of Depression Headache: :
It consists of psychiatric consultation and antidepressant drugs.
E. Cluster Headache
It is mainly the disorder of middle-aged men.
Clinical features of Cluster Headache:
Episodes of severe unilateral pain around one eye occur daily (more in night) for 4-8 weeks.
Episodes awaken the sleeping patient and last for 15 minutes to 3 hours.
It is associated with ipsilateral conjunctival congestion (red eye), lacrimation, nasal congestion and rhinorrhea.
Occasionally, patient may develop Horner’s syndrome, which may be transient or longstanding.
Spontaneous remission may last for weeks or months. In cases of chronic cluster headache there is no period of remission.
Triggers for Cluster Headache: They include alcohol, stress, glare, or specific foods.
Treatment of acute episode of CLUSTER HEADACHE:
Oral drugs are usually not effective.
Following measures are often effective.
Sumatriptan: Subcutaneous (6 mg) or intranasal (20 mg/spray).
Oxygen: Inhalation of 100% oxygen (12–15 L/min for 15 minutes) via a non-rebreather mask.
Zolmitriptan: 5–10 mg nasal spray.
Dihydroergotamine: 0.5–1 mg IM or IV
Xylocaine viscous: 1 mg of 4–6% solution intranasally.
Prophylactic agents for Cluster Headache:
They include cyproheptadine, lithium carbonate, verapamil (240–960 mg daily), topiramate (100–400 mg daily) and methysergide (2–12 mg daily).
Transitional therapy for Cluster Headache :
Prophylactic agents are not immediately effective therefore following drugs are used in transitional therapy.
Ergotamine tartarate: Rectal suppository (0.5–1 mg) at night or twice daily, 2 mg daily orally, or 0.25 mg subcutaneously 3 times daily for 5 days per week.
Prednisone: 60 mg daily for 5 days followed by gradual withdrawal.
Dihydroergotamine: 9.25 mg IV over several days or 0.5 mg IM twice daily.
Xylocaine and corticosteroid: Greater occipital nerve block with local injection of xylocaine and corticosteroid.
F. Post-traumatic Headache
Clinical features of Post traumatic Headache:
This constant dull headache develops within a day or so following closed head injury, may worsen over weeks and then gradually subsides.
Throbbing sensation may be localized, lateralized, or generalized.
Headache developing after 2 weeks of injury is usually not related to head injury.
Associated features of Post traumatic Headache:
Patients may have associated nausea, vomiting, or scintillating scotomas.
The headache is associated with lightheadedness, irritability, difficulty in concentration and in coping with work.
Other associated complaints which may be present include impaired memory, emotional instability and increased irritability.
Vertigo of Post traumatic Headache: The associated disequilibrium may have rotatory component and aggravated by postural change or head movement.
Investigations of Post traumatic Headache:
They are usually not helpful. CT/MRI scans are usually normal. EEG may show nonspecific changes. ENG may suggest peripheral or central vestibulopathy.
Treatment of Post traumatic Headache:
Reassurance with graduated rehabilitation is important.
If simple analgesics fail, then amitriptyline, antiseizure drugs, propranolol, or ergot derivatives are used.
G. Cough Headache
This is usually a self-limiting disease.
In some patients it may persist for several years.
Clinical features of Cough Headache:
This transient (few minutes or less) but severe headache is produced by coughing, straining, sneezing and laughing.
CT/MRI scans: They should be done in all patients to rule out space occupying intracranial lesions and Arnold-Chiari malformation.
CT/MRI may be repeated annually as a small lesion may not show initially.
Treatment of Cough Headache::
Lumbar puncture may alleviate the symptoms completely.
Indomethacin (75–150 mg daily) is effective in some patients.
H. Giant Cell (Temporal or Cranial) Arteritis
In addition to the superficial temporal, other arteries which are often affected are vertebral, ophthalmic and posterior ciliary arteries.
Early diagnosis and treatment can prevent blindness which is usually permanent.
Clinical features of Giant Cell (Temporal or Cranial) Arteritis:
This unilateral severe throbbing headache occurs in elderly people.
The headache is often associated or preceded by myalgia, malaise, anorexia and weight loss. The superficial temporal artery becomes thickened, tender and nonpulsatile.
Jaw claudication (pain during chewing and talking) is pathognomonic.
Many patients present with blindness (transient or permanent) and diplopia. Some patients may develop stroke, hearing loss, myelopathy and neuropathy.
Biopsy:
Prompt temporal artery biopsy (at least 2 cm in length) is important. Biopsy shows lymphocytes, histiocytes, plasma cells and giant cells in media and adventitia.
Treatment of Giant Cell (Temporal or Cranial) Arteritis:
On clinical suspicion immediately initiate prednisone (60 mg/day for 1 month before tapering).
In cases of blindness intravenous pulse Methylprednisolone (1 gm daily for 3 days) is given.
When tapering prednisone, erythrocyte sedimentation rate (ESR) or C-reactive protein is a useful but not absolute guide.
Aspirin: Low dose aspirin (up to 81 mg/day orally) may prevent blindness and stroke.
Methotrexate: It is modestly effective.
Anti-tumor necrosis factor (TNF) therapies: They are not effective.
Complications of Giant Cell (Temporal or Cranial) Arteritis:
Thoracic aortic aneurysm can result in aortic regurgitation, dissection and rupture.
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