Headche د.عبدالرحمن سلام

8/3/2019 Headche د.عبدالرحمن سالم

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HEADACHE

Prepared by :

Dr : Abdulrahman sallam

Associated Prof. of Neuropsychiatry

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HEADACHE

Definition:

It is discomfort of pain in the head (it is a

symptom and not a disease)

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Pain sensitive structures

A-Extracranial

(arteries, muscle of cranium and pericranium)

All tissues covering the cranium (cranium after periostium inward

non sensitive) .

B-Intracranial

1- Arteries (big ones at the base of the brain, cerebral and dural

arteries)

2- Part of the dura which cover the base of the skull

3- Nerves carrying pain fibers 5th, 9th, 10th of cranial nerves

and upper 3 cervical sensory roots .3



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Mechanism of headache

1-Vascular: through vasodilatation and stretching of arteries and veins,

thus stimulating pain fibers in their wall e.g. migraine.

2-Muscular: through spasm occipitofrontalis and neck muscles

e.g. psychogenic .

3-Pressure ,traction or distortion :of intracranial pain sensitive

structures e.g. S.O.L .

4-Inflamation of sensitive structure: e.g. meningitis, arteritis and

neuritis .

5-Refferad pain : from structure within the head e.g. disease of eye,

nasal, ear sinus, and teeth also from thoraco-abdominal viscera e.g.

constipation .



Description of headache:

1- Tim sitting : continuous or intermittent and duration.

2- Distribution: local or generalized.

3- Character of pain: thropping, aching, stabbing ,

stretching and bursting (commonly organic) but sense of

sever pressure, weight on the head, marked tightness,

numbness or bizarre description (commonly

psychogenic ).

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4- Severity: interference with the job of patient, sleep

and response to analgesic or not.

5- Aggravating factors : physical effort or mental strain.

6- Symptoms associated with headache:

nausea, vomiting, visual disturbance, depression,

anxiety, insomnia, difficulty in concentration and easy

fatigability.



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History:

History of head injury, Infection of ear sinuses,

mental exhaustion or psychogenic disorder and family

history of similar condition.

Examination:

Mental state, head inspection, fundoscopy, B.P,

skull x-ray, EEG, CT-brain and brain MRI if necessary.





I- Psychogenic :

A-Etiology: Anxiety, depression and neurosis .

B-Mechanism:

1- spasm or tonic contraction of skeletal musclesof the head and neck .

2-change in the tone of cranial vessels

(vasoconstriction followed by rebound vasodilatation) .

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C- Characters:

continuous and long duration (weeks, months or even

years) generalized non responsive to analgesic drugs ,

aggravated by psychogenic factors .

E- Examination:

no evidence of organic illness .



II-Referred pain :Etiology : e.g. Eye errors of refraction particularly

hypermetropia which associated with prolonged

contraction of frontalis , temporalis and nuchal muscle,

teeth dental caries especially molar, sinusitis and otitis

media.

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III-Fibrositis:

A- Etiology: Rheumatic of the scalp or the sub

occipital tissues .

B- Character: Continuous (days , weeks)

aching, shooting , stabbing in character aggravating by

head and neck movements , coughing and sneezing .

Also associated with tenderness of affected region .



IV-Neuritis and neuralgia

A-Interstitial neuritis

Etiology: Inflammation of the connective tissue of

peripheral nerve, neurotropic virus, septicemia

metabolic abnormality (e.g. diabetic) or repeated

trauma (pressure neuritis ) e.g. occipital headache due

to cervical spondylosis. Pain result firstly by

inflammatory exudates later by over growth of

connective tissue .

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V-Temporal arteritis

Etiology: It is regarded as immune complex disorder .

Character: subacute onset with malaise and fever

continuous but worse at night corresponds to distribution

of affected vessels ,aggravated by strain, thickened,tenderness nodules and diminish pulsation by palpation of

temporal artery, periarterial redness and swelling for 10

days but artery remain tender for along time, diplopia or

unilateral blindness (affecting ophthalmic artery) also

E.S.R is high.16



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VI-Intracranial space occupying lesion

At first paroxysmal and later become permanent, at

first it is localized and later it is diffuse and generalized

Paroxysmal develop during lying down during sleep due

to increase tension in the head .

The patient may be awaked early in morning due to

headache and he may obtain some relief by sitting in the

bed .



VII-Post-traumatic headache.

Etiology

1- Psychogenic due to symptoms of memory

disturbance and irritability .

2- Organic due to meningeal adhesion, sensory

nerve fibers injury, sustained contraction of skeletalmuscle of head ,neck and distension blood vessels

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Character

Paroxysmal, recurring for few months (3 - 4) maximal

at the site of injury and spread to variable extent, occur

spontaneously or a result of physical efforts, sharp,

shooting or thropping in character .



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VIII- Meningeal headache

Etiology

Meningitis, subarachnoid hemorrhage lead to

displacement of blood vessel by exudates or blood and

irritation of blood vessels .

Character

Continuous, worse at night, severe at occipital region,

boring or shooting in character associated with neck

rigidity and CSF change .



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IX- Headache due to C.S.F. pressure change

1- Increase pressure: due to stretch and displacement

pain sensitive structure intracranial, improved by sitting .

2- Decrease pressure: due to traction on pain sensitive

structure intracranial improving by lying down

throbbing in character .



X- Hypertensive headache

Mechanism: stretching extra cranial vessels

Character: intermittent, localized in occipital

region and throbbing .

when it is sever associated with vomiting .

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XI-Infection and toxication headache

Mechanism: vasodilatation and stretching

intracranial vessels due to histamine release .

Character: continuous, generalized or frontal

localization, throbbing and sense of fullness associated with

symptoms of infection and toxication .



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XII- Miscellaneous group of headache

1- Cough headacheIt is may be some sort of intracranial arteritis and coughing

stretches the inflammed artery .

2- Visceral headacheDisease of the intra-thoracic and intra-abdominal viscera may

cause headache through the central connection between the sensory

nucleus of the trigeminal and vagus nerve in the brain, by this way

pain from thoracic and abdominal viscera may be referred to the head .



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3- Headache due to constipation: the same mechanism as

before .4- Headache due to Anaemia :due to increase the

amplitude of pulsation .

5- Headache due to hypoglycemia : due to intracranial

vasodilatation .

6- Allergic headache: due to oedema .



XII-Migraine

Definition: It is a paroxysmal headache commonly hemicranial

preceded by aura .

Etiology and pathology :The condition is due to vascular change

first vasoconstriction fallowed by vasodilatation .The aura is due to

vasoconstriction of one branch of the internal carotid artery and

headache occurs due to vasodilatation and stretching of the branch of

external carotid artery

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Clinical pictures:

usually there are two phases

1- Aura:

It lasts 15 - 30 minutes before the onset of headache, it

is usually visual, it my be sensory e.g. tingling in the

hand spreading slowly up wards to involve the lips and

tongue, rarely consist dysphasia or hemiparesis .



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2- Headach:

Its duration usually several hours, but rarely it remainsfor 2 - 3 days, It starts in localized area on one side

(often the temple) and gradually spreads to the whole

head .It sometimes radiates into the neck or the face due

to involvement of the occipital and facial vessels. It is

thropping in character, Intensified by all forms of exertion and my be associated with nausea and vomiting

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Others rare type of migraine

1- Ophthalmic migraine: which is recurrent attacks of

headache associated with paralysis of one or more ocular

nerve which persist for days or week after the attack and

tends to become permanent .Probably it is due to oedema

of the wall of the internal carotid artery with pressure on

the ocular nerves in the wall of cavernous sinus .



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2- Basilar artery migraine:

It is due to involvement the branches of the basilarartery leading to disturbance of brain stem function

during the attack leading to giddiness, ataxia, vertigo,

dysartheria and even short period of loss of

consciousness .



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Headche د.عبدالرحمن سلام