Headache is a common symptom, and there are many causes of headache. Only a few tissues in the skull have nociceptive fibers, such as the proximal end of the arterial ring and its branches at the base of the brain, the middle meningeal artery and venous sinus, vein, and the meninges at the base of the skull. occipital and cervical regions. Pain caused by extracranial lesions of the periosteum, scalp, facial skin vessels, cervical muscles and middle ear, dental pulp, and intraorbital tissues is mostly limited. Systemic diseases often result in increased blood flow to the brain, which can also produce headache.
[Etiology].
(a) Migraine Migraine and cluster headache.
(II) Intracranial cavity diseases
1.Inflammatory diseases Meningitis, encephalitis, brain abscess, arachnoiditis, etc.
2.Intracranial tumors, parasitic cysts and granulomas.
3.Cerebrovascular disease Cerebrovascular accident (cerebral hemorrhage, cerebral thrombosis, cerebral embolism, subarachnoid hemorrhage), hypertensive encephalopathy, aneurysm, venous thrombosis, arteriovenous malformation, etc.
4.Cranial trauma Concussion, contusion, epidural and intradural hemorrhage, chronic headache after cranial trauma (post-concussion sequelae).
5.Intracranial low pressure headache.
6.Headache-type epilepsy, post-epileptic headache.
(C) Lesions adjacent to the cranial cavity
1.Osteochondritis, osteomyelitis, cranial deformity osteitis of the skull.
2.Trigeminal neuralgia, glossopharyngeal neuralgia and occipital neuralgia.
3.Ocular diseases (glaucoma, refractive and regulatory disorders).
4.Sinusitis, nasopharyngeal cancer.
5.Otitis media and inner otitis.
6.Dental pulpitis.
7.Tension headache.
(D) Systemic and somatic diseases of certain systems
1.Acute and chronic infectious diseases Influenza, typhoid, pneumonia, malaria, etc.
2.Acute and slow good poisoning
(1) Exogenous: carbon monoxide, ethanol, belladonna, opium, lead, mercury, etc.
(2) endogenous: uremia, constipation, diabetes, gout, etc.
(3) Internal diseases: heart disease, emphysema, hypertension, anemia, menopausal syndrome
(4) Hyperthyroidism.
(5) Neurofunctional headache
Key points of differentiation
(a) Medical history Pay attention to certain characteristic circumstances in the history of headache.
1. Acute and slow onset
(1)Acute onset: such as acute infection (if intracranial inflammation and accompanied by high fever, suggest meningitis, encephalitis, etc.), head trauma, subarachnoid hemorrhage, headache after lumbar puncture, etc.
(2) Chronic progressive: Headache of increased intracranial pressure and some chronic toxemia, which is characterized by severe pain in the early morning, often accompanied by vomiting, and then gradually relieved, and the same pattern reappears on the second day, such as intracranial tumor, abscess, subdural hematoma, uremia, sinusitis and other toxic states, etc.
2.Paroxysmal or persistent headache with periodic attacks, each attack lasts for several hours, and some last for several days.
(1) Recurrent paroxysmal headache: The most representative ones are migraine and cluster headache. In addition, there are brain contusion hypertension, cerebral artery disease, cervical spine disease and headache epilepsy.
(2) Persistent headache: the pain is located on both sides of the frontal-occipital or facial area with bunching-like pain or distension, which can occur in tension headache, deformational osteitis, chronic inflammation of the skull, menopausal syndrome, post-concussion syndrome, and neurofunctional headache. However, hypertensive patients mostly have frequent head pressure, but also pulsating or blast pain, which is often located in the occipital region and neck, and may diffuse throughout the head.
3.Headache caused by extracranial local factors The nature of such headache can be acute onset or chronic progressive, such as glaucoma, iritis, sinusitis, frontal sinusitis, cranial lesions, etc.
(1) Headache due to eye disease is often a vague pain located near or behind the eye. In retrobulbar optic neuritis, the pain is located inside the eye or at the superior edge of the orbit, especially when the eye is moving. Refractive error headache is a dull frontotemporal pain and heaviness, often after reading, that can last for hours and is often accompanied by painful reflex head and neck muscle spasms. Farsighted people may have frequent headaches, while nearsighted people generally have fewer headaches unless they have extreme astigmatism. The latter is initially limited to the orbital area, and then extends to the orbital rim and finally to the distribution area of the ophthalmic branch of the trigeminal nerve. The pain may be accompanied by nausea, vomiting, vision loss, corneal clouding and increased intraocular pressure.
(2) Headache near the ear or mastoid area is often caused by acute otitis media, external ear canal boils, mastoiditis, auricular band sores, cavernous sinus thrombosis, acute facial neuritis, etc. However, tonsillitis, temporomandibular joint lesions, and mandibular molar disease can also cause reflex headache.
(3) Paroxysmal severe pain in the cheek, commonly known as trigeminal neuralgia, and trigeminal neuralgia in young patients with sensory disturbance in the trigeminal nerve distribution area only, must consider the possibility of sinusitis and nasopharyngeal carcinoma. Acute sinusitis, mostly confined to the site of the diseased sinus, but the pain of butterfly sinusitis is often located in the top of the head, sieve sinusitis is located in the root of the nose, and maxillary sinusitis is located in the upper teeth.
(4) Pain in the posterior wall of the pharynx and tonsillar fossa can be caused by glossopharyngeal neuralgia, tonsillitis, pharyngitis, etc.
4.The nature of headache, attack time and the relationship between systemic visceral diseases
The headache associated with various systemic febrile diseases is often concentrated in the forehead, posterior occipital region or diffused throughout the skull, and its nature is mostly pulsating, and coughing, sneezing and shaking the head can aggravate the headache.
In the early stage of certain exogenous toxic diseases, there are often no obvious signs and symptoms, but the only manifestation is headache, which is mostly diffuse and dull in nature, with varying degrees, such as occupational diseases with a history of chemical exposure. Headaches caused by endotoxicosis are most commonly associated with nephritis or hypertension. Headaches in patients with hypertension vary in severity and severity, and tend to be frequent tight pressure in the head, or pulsating or blast pain, often located in the occipital region and neck, or diffuse throughout the head, and are most severe in the early morning when waking up. The headache is characterized by blood flow disorder headache caused by cardiac insufficiency, emphysema, etc. It is a dull pressure pain, mainly located in the occipital region, and can be aggravated when the collar is too tight or when coughing.
(II) Physical examination
1.General physical signs
(1) Pay attention to whether there is fever, high fever suggests encephalitis, meningitis, brain abscess, heat stroke and atropine poisoning, etc.; low temperature is mostly seen in alcohol poisoning, sedative poisoning, etc.
(2) Protrusion of the eye is cavernous sinus thrombosis, carotid cavernous sinus fistula, arteriovenous nerve palsy, and intraorbital tumor.
(3) If there is murmur in the eye and neck area, it is carotid cavernous sinus fistula or carotid artery thrombosis.
(4) Note the presence of herpes zoster in the forehead and auricle, or scar left behind, herpes zoster in the auricle, and also vertigo, facial palsy and hyperalgesia in the trigeminal innervation area.
(5) Nerve pressure points, such as trigeminal neuralgia with pressure pain in the supraorbital foramen and infraorbital foramen; the pressure pain point of occipital major neuralgia is at the midpoint between the mastoid process and the first cervical vertebra; the pressure pain point of occipital minor neuralgia is located at the posterior superior edge of the sternocleidomastoid muscle; all of these can help to differentiate trigeminal neuralgia and occipital neuralgia. About half of the cases of carotid arteritis have tenderness or diminished vascular pulsation in the superficial temporal artery.
(6) Localized swelling of the head is seen in sinusitis, temporal arteritis, jaw arthritis, dental pain, osteochondritis of the skull, osteomyelitis, cellulitis, etc.
(7) Restricted neck movement with pain, such as neck thrust disease, neck mass, occipital foramen magnum syndrome, etc.
2.Companying neurological signs
(1)Optic papilloedema can occur in intracranial tumor, hematoma, brain abscess, cerebral parasitosis, cavernous sinus thrombosis, etc.; those with visual field defects, mostly optic cross lesions or temporoparietal occupying lesions; optic nerve atrophy or vision loss can occur after optic neuritis and cranial hypertension.
(2) In unilateral actinic nerve palsy or with signs of meningeal irritation, aneurysm rupture and meningitis are seen.
(3) With head and facial hyperalgesia can be caused by trigeminal neuralgia, trigeminal neuritis, auricular herpes zoster, occipital neuralgia, etc.
(4) Those with hemiparesis, hemianesthesia, ophthalmoplegia, and ataxia can occur due to cerebrovascular accident, encephalitis, intracranial occupying lesions, and cranial trauma, etc.
(C) Laboratory tests
Cerebrospinal fluid examination has decisive value for intracranial inflammation and hemorrhagic lesions, but it should not be performed easily when there is increased intracranial pressure, and low pressure headache is possible in those with low cranial pressure. EEG, transcranial Doppler ultrasound (TCD), brain imaging (CT, MRI) or cerebral angiography (DSA), radionuclide brain scan (SPECT) can be considered for vascular diseases, intracranial infections, and intracranial occupying lesions. Blood and urine routines, serum reactive hormone flocculence test (vDRL), and dense spirochete fluorescent antibody adsorption test fasting glucose are helpful to check for systemic infections, anemia, neurosyphilis and diabetes mellitus. Temporal arteritis can be repeated with blood sedimentation, superficial temporal artery blood flow or biopsy.
【Treatment】.
The principles are.
1.Actively deal with and treat the primary disease;
2.Appropriate use of antipyretic and analgesic agents such as Somigelia, Migranin, or a small amount of codeine, cranial pain, etc.;
3.Add tranquilizers or sedatives for anxiety and irritability, and add antidepressants for depression;
4.Treatment for the pathogenesis, such as dehydration diuretics for high cranial pressure and hypotonic fluids for low cranial pressure; ergot preparations for dilated headache; massage, heat therapy, painful nufcaine closure for relaxed contracted muscles; closure therapy for superficial neuralgia; cerebrospinal fluid replacement, etc.
Several common headaches are treated.
(I) Migraine
1.Preventive treatment
Calcium channel blocker Cipro 5J, once a night;
or nimodipine 40J, three times a day.
β-blocker Propranolol 10-20J, four times a day.
Phenothiazine 0.5J, one to three times a day.
2.Treatment during seizure
Ergotamine caffeine, 1 to 2 tablets orally immediately, plus 1 to 2 tablets 1 hour later if necessary. No more than 4 tablets daily, no more than 10 tablets in 1 week. Analgesics, such as aspirin and bulk pain. Tretinoin, such as Yingminger, etc.
3. Chinese patent medicines such as Tongtian Oral Liquid, Chuanxiong Su, Nourishing Blood and Clearing Brain Granules, etc.
(II) Tension headache
1.General treatment Eliminate worries and relaxation exercise.
2.Medication Appropriate analgesics, do not abuse.
(C) Cluster headache
1.Acute attack treatment Appropriate analgesics, small doses of hormones.
2.Preventive treatment Keep a regular life and insist on endurance exercise.
(iv) Cervical migraine.
Cervical traction, taking vasodilator drug nimodipine 20mg 3 times/d, ciprofloxacin 5-10mg per night, carbamazepine (0.1g 3 times/d), prednisone (20mg
1 time/d) or closed stellate ganglion for coexisting cervicothoracic radiculitis.
(v) Myoconstriction headache.
Massage, hot compresses and taking tranquilizers and sedatives, and closing the muscle pressure points with 2-5 ml of 2% lidocaine. Cervical spine traction should be performed in cases of cervical spine hyperplasia or injury.
(vi) Neuritis headache.
The cranial surface nerve sites such as Fengchi point (occipital neuralgia) and supraorbital notch (supraorbital neuralgia) can be closed with 2-5 ml of 2% lidocaine; oral carbamazepine (0.1g 3 times/d) or phenytoin sodium (0.1g 3 times/d) can also be used for treatment.