Headache is pain anywhere in the head and is not a disease in itself, but a very common clinical symptom that can be seen in a variety of diseases. According to statistics, 96% of people experience a headache in their lifetime, and almost all people over the age of 40 have experienced a severe headache. In a normal person, the cranial cavity contains mainly brain tissue, cerebrospinal fluid, cerebral blood vessels and the blood in the cavity. Under normal circumstances, the volume of the cranial cavity is compatible with the volume of the contents, and a certain pressure of 80-200 mmH2O is maintained in the cranial cavity. when a certain space in the cranial cavity is occupied by a focal lesion, an increase in intracranial pressure occurs and causes headache.
Myotonic headache.
It is mostly seen in young adults, mostly in women. It is often triggered or aggravated by anxiety, exertion and emotional tension, so it is also called tension headache. Its pathological basis is due to persistent contraction of head and neck muscles and secondary vasoconstriction of ischemia to produce “pain-causing substances”. The headache may feel like a heavy pressure or tightness, or it may be a pulling pain or swelling pain. The pain is mostly in the posterior occipital region, cervical region and bilateral frontal region, and is mostly persistent. It can be relieved after rest. There are no other positive signs on examination.
Vascular headache.
(1) Migraine: hemiplegic headache, starting mostly with dull pain in the supraorbital, retroorbital or frontotemporal area on one side, but also with pulsating throbbing pain.
(2) Unruptured aneurysm with arteriovenous malformation (AVM): usually does not produce headache, but posterior communicating aneurysm or internal carotid aneurysm can cause headache on one side, mostly fixed in the affected orbit and frontal area, with moderate headache. AVM can cause severe pain on the affected side of the head, which can be recurrent, and some patients may have seizures or mild hemiparesis of the contralateral limb.
(3) Ischemic stroke: It can also cause headache, which is pulsating pain. It may be associated with extracranial arterial dilation. (4) Hypertensive headache: Most often seen in middle-aged and elderly people, the headache may be in the occipital region, frontal region with full headache, and is a persistent distending or throbbing pain. It is often accompanied by dizziness, high blood pressure, even fundus hemorrhage, vision loss and severe headache.
Psychogenic headache.
Neurosis, depression, hysteria, etc. are all in this category and often present headaches. The main cause of headache is the lowering of the threshold of pain tolerance and muscle tension, the pain site is not fixed, the degree is not too intense, often accompanied by insomnia, memory loss, dizziness, inattention, and generally does not affect daily life. There are no signs of organic lesions on clinical examination.
Trauma-induced headache.
(1) Post-concussion headache syndrome: mostly accompanied by dizziness, vomiting, insomnia, memory loss mental tension.
(2) In addition to intracranial hemorrhage, most of them are caused by extracranial factors. The common ones are: (1) headache caused by local scalp tissue injury or scar; (2) head injury with cervical spine injury, which causes pain behind the ear or occipital region due to injury of the cervical nerve; (3) headache located in the temporal and frontal regions, often intermittent or pulsating headache, related to the expansion of the branches of the external carotid artery; (4) persistent and non-pulsating headache due to persistent contraction of the neck muscles after the injury.
Neuralgia.
(1) Trigeminal neuralgia: Primary trigeminal neuralgia is mostly seen in middle-aged and elderly people. The pain is characterized by paroxysmal sharp pain in the distribution area of the branches of the trigeminal nerve on the affected side of the face, and the nature of the pain is such as cutting, burning, electric shock and so on. Each attack usually lasts for a few seconds or minutes and is repeated several times a day. About 30-50% of patients have one or more “trigger points” that cause severe pain when touched or stimulated. Secondary trigeminal neuralgia is mostly caused by CPA tumor or nasopharyngeal carcinoma compressing the nerve.
(2) Occipital neuralgia: It refers to occipital neuralgia, occipital neuralgia and auricular neuralgia, which is caused by the stimulation of posterior cervical sympathetic nerve. Mostly one side or both sides, the pain site is in the occipital region or the back of the neck, and there is pressure pain at the outlet of the greater occipital nerve and above the mastoid process. Barre syndrome: The headache is mainly in the occipital region and radiates to the back of the eyes or forehead, sometimes to the shoulders or upper extremities. The pain is often triggered or aggravated by changes in body position, fatigue, and excitement. Some of them are accompanied by vertigo, tinnitus visual impairment, etc.; there may also be abnormal sensation and burning sensation in the pharynx.
Intracranial tumors.
There are primary tumors and secondary tumors (metastases); there are mostly three main signs of intracranial hypertension: headache, vomiting, and optic papilledema. The symptoms get progressively worse over time. Tumors in the cerebellar vermis appear later, mostly after optic papilloedema, with headache in the front and back of the head; tumors in the posterior cranial fossa appear early and the pain is quite intense, mostly in the back of the head, and may radiate to the neck and forehead. Tumors in the saddle area often cause pain behind the eyes or both temporal sides and a feeling of swelling behind both eyes. The attacks are more frequent in the early morning and at night. Intracranial tumors can cause different kinds of headache according to the site of occurrence, and also have their special manifestations for differential diagnosis. For example, in addition to headache, hearing loss, tinnitus, vertigo, facial numbness and cerebellar dysfunction are often associated with auditory neuroma. In pituitary tumors, headache is often in the frontotemporal and posterior part of the eye, and there are also loss of vision, visual field loss and endocrine disorders. Tumors near the motor area of the cerebral hemispheres may present with weakness hemiparesis and convulsions of one limb.
Intracranial hematoma.
(1) Traumatic intracranial hematoma: history of trauma, headache, dizziness with sharp aggravation or continuous aggravation, with frequent vomiting, followed by coma, dilated pupils, impaired movement of the contralateral limb, etc.
(2) Hypertensive cerebral hemorrhage: middle-aged and elderly people with a history of hypertensive atherosclerosis. At the onset (before hemorrhage), there is mostly severe headache, jet-like vomiting, hemiplegia of the limbs, slurred speech, and soon coma.
(3) Subarachnoid hemorrhage: Mostly caused by rupture of intracranial aneurysm and vascular malformation.
Aneurysm headache.
Sudden onset, severe, often constant on the affected side, with fluctuating pain, drilling pain or distension, some with fluctuating proptosis. Vascular malformation headache: mostly on the affected side, with paroxysmal attacks, some with typical migraine. All present with signs of meningeal irritation, and lumbar puncture cerebrospinal fluid is hemorrhagic.
Other causes of intracranial hemorrhage.
Bleeding from intracranial tumors, intracranial venous thrombosis, bleeding crises caused by blood disorders such as hemophilia, thrombocytopenic purpura, aplastic anemia, etc. can cause headache, but the characteristics of headache are closely related to the primary cause.
Brain abscess.
(1) Etiology: 60% of brain abscesses are complicated by otitis media or mastoiditis, and the rest originate from hematogenous infection or open cranial injury, etc.
(2) Characteristics of headache: Headache is severe, persistent and progressive, accompanied by vomiting and impaired consciousness, and accompanied by fever and elevated white blood cells.
Inflammatory headache.
Headache can occur in all infectious diseases of the central nervous system. Early posterior occipital pain is more common, and later it turns into full headache, and the nature of headache is dull pain, swelling pain or throbbing pain, and the headache is aggravated by physical activity. Headache caused by meningitis is severe and persistent, often with throbbing pain, accompanied by fever, vomiting and neck ankylosis, positive kernig’s sign, and increased leukocytes in cerebrospinal fluid examination.
Epileptic headache.
Paroxysmal headache can be a major manifestation of epileptic seizures. The headache is mostly manifested after the seizure, and the pain is mostly in the frontal area in a transient seizure. The intervals between seizures are completely normal. It is more common in children. There are epileptic waves on EEG.
Headache caused by face and neck disorders.
(1) Headache from eye diseases: Certain eye diseases often cause headache, and the pain is often confined to the orbit, forehead or temporal region. (1) Acute attacks of glaucoma often have severe headache and eye pain, accompanied by nausea, vomiting, and visual disturbance. (2) Refractive error (myopia, hyperopia or astigmatism) causes headache due to persistent contraction of extraocular muscles and frontotemporal muscles caused by excessive fatigue of the eye muscles, and the headache is aggravated after gazing for a long time. (3) Inflammation of orbital tissues, optic neuritis, and retrobulbar tumors can cause pain in the eye and frontal area. It is also accompanied by visual impairment.
(2) Headache of nasal and pharyngeal diseases: acute sinusitis is often accompanied by more intense headache, and inflammatory pain of frontal sinus, sieve sinus and butterfly sinus is mostly in the forehead, often dull pain or hidden pain, which can radiate to the orbit and temporal region. Inflammatory pain in the maxillary sinus is mostly in the face and may radiate to the forehead. Headache is often an advanced symptom of sinus malignancy, and frontal carcinoma mostly causes frontal headache on the affected side. Sieve sinus carcinoma can cause pain in the nasal bridge, etc.
(3) Headache of oral diseases: toothache and gingival inflammation are mostly persistent burning pain, swelling pain or throbbing pain, and the pain is confined to the lesion and radiates to the frontal-temporal area. Temporomandibular joint disease becomes persistent dull pain, which may radiate from the local to the temporal area, and the pain is aggravated when opening the mouth.
(4) Headache of cervical spine disease: The causes may be (1) persistent contraction of cervical muscles; (2) compression or injury of cervical nerve roots with cervical muscle spasm; (3) insufficient blood supply to the vertebrobasilar artery system. The headache is more common in the occipital region and lower occipital region, mostly involving pain, and may be accompanied by pain and numbness in the upper extremities and limited neck movement.
Other causes of headache.
Headache during menstruation in women, or headache caused by endocrine disorders and anxiety during menopause; headache caused by vasodilatation after heavy alcohol consumption; headache caused by low cerebrospinal fluid pressure after lumbar puncture; headache caused by sudden change in brain pressure after pneumoencephalography or ventriculography.
Ancillary tests for headache diagnosis.
(1) CT: the most direct, rapid and easy to perform.
(2) MR: comprehensive, three-dimensional reflection of the lesion.
(3) DSA: the gold standard for the diagnosis of vascular lesions.
(4) TCD: to determine the degree of vascular spasm.
(5) EEG: determination of epilepsy.
Treatment of headache.
(1) Functional headache: conservative treatment, physiological adjustment, Chinese medicine dialectic, acupuncture, etc., combined with western medicine drug-assisted treatment, can mostly cure or relieve.
(2) Organic headache: specialist drug treatment, tumor compression requires surgical treatment.