1. What are the common types of headaches in the pain clinic?
Headaches are the most common type of pain and almost everyone has a history of headaches during their lifetime. Headaches may be a transient symptom or a concomitant symptom of another disorder, but they may also be a separate disorder. There are many kinds of headache diseases, and the most common types of headaches in pain clinics are: cervicogenic headache, migraine, tension-type headache, cluster headache, etc. However, there are great difficulties in treatment because their etiology and pathogenesis are complex or even unclear.
2.What are the pathogenesis of cervicogenic headache?
Cervicogenic headache can be divided into neurogenic pain and myogenic pain according to the different parts of the nerves involved. The stimulation of sensory root fibers of nerve roots causes neurogenic pain, while the stimulation of its ventral motor nerve roots is myogenic pain.
(1) Relationship between anatomical basis and cervicogenic headache
The fibers of the 2nd cervical nerve and the 3rd cervical nerve together form the greater occipital nerve, the lesser occipital nerve and the greater auricular nerve, and these nerves are the main nerves that conduct cervicogenic headache. The branches of these nerves are close to the angle of the vertebral artery before it enters the cranial cavity through the foramen magnum, and are susceptible to irritation and injury from the vertebral prominence and muscle attachments.
Inflammation, ischemia, injury, compression and even inappropriate massage of soft tissues can affect the function of the nerves and trigger cervicogenic headache.
(2) Degenerative degeneration of the cervical spine and intervertebral discs causing intervertebral foraminal stenosis
After degeneration or herniation of cervical disc, the disc becomes “hard” by “fibrosis”, and later, with the tissue repair and calcification, osteophytes can be formed, which deform the intervertebral foramen, and the space of the intervertebral foramen is encroached, thus provoking the nerves that pass through it, resulting in pain and neurological dysfunction. (3) Cervical disc degeneration
(3) Non-bacterial inflammation caused by degenerative degeneration and herniation of the cervical intervertebral disc
Cervical disc degeneration and herniation, and release of disc material can directly cause non-bacterial inflammation and edema. The human immune system views the disc material as a foreign body and produces immune rejection reactive inflammation, causing cervical discogenic radiculitis. In addition to the direct production of radicular pain, pain can also be produced by the release of inflammatory mediators at the end, causing soft tissue inflammation within the distribution area. This is the mechanism by which intractable cervicogenic headache occurs in some patients.
(4) Muscle spasm
Cervicogenic headache can also be produced in the muscle tissue of the neck. On the one hand, when the nerve governing the movement is compressed or inflamed, it can cause reflex cervical muscle spasm; on the other hand, persistent chronic muscle spasm causes tissue ischemia, and metabolites gather in the muscle tissue, causing myofasciitis and pain, and can directly stimulate the nerve trunks and nerve endings traveling in the soft tissue to produce pain.
Long hours of work with head down, muscles need to contract continuously to maintain posture, which reduces muscle blood supply and causes muscle spasm, and makes ligaments and myofascia susceptible to injury; long and tedious mental activities or physical labor are most likely to cause tension in the nerves and muscles of the neck among all parts of the body, which are common causes of cervicogenic headache in adolescents.
3.What are the clinical manifestations of cervicogenic headache?
Patients with cervicogenic headache are mostly aged 20-60 years old and are more common in women. In the early stage, it is mostly discomfort in the occipital area, behind the ear, or under the ear, and later turns into stuffiness or soreness, and pain gradually appears. The painful area may extend to the forehead, temporal region, top, and neck. In some cases, pain in the upper extremity of the ipsilateral shoulder and back may occur at the same time. The pain may be aggravated by cold, exertion, alcohol consumption, and emotional excitement. Some patients have tinnitus, ear swelling, eye stuffiness, and stiffness in the neck. Most patients prefer to press the painful area with their hands for relief during painful episodes. Oral non-steroidal anti-inflammatory drugs (e.g., fen-phen) can reduce the headache.
The incidence of cervicogenic headache is higher among desk-bound workers. The quality of life and work is significantly reduced due to decreased work efficiency, reduced concentration and memory, depression, irritability, and irritability.
The cervical spine degenerative changes can be seen in different degrees in X-ray examination, and some patients can see cervical intervertebral foraminal stenosis, anterior and posterior edge of vertebral body hyperplasia, or widening and thickening of spinous process, and calcification of supraspinous ligament; there are no special changes in CT examination, and a few patients can see cervical disc herniation.
4.Do you know about migraine?
There are various misconceptions about migraine among the public. Some patients believe that migraine is only a headache that occurs on one side of the head, but not a disease; some patients firmly believe that the headache must be caused by insufficient blood supply to the brain or a tumor, so they go around for medical examination but get nothing; some patients believe that the headache cannot be cured, so they simply do not receive treatment and let the disease torment them; there are also some patients who blindly purchase over-the-counter pain medications or even use narcotic drugs for a long time, which complicates the condition. There are also some patients who blindly purchase over-the-counter pain medications or even use narcotic pain medications for a long time, which may complicate the condition or cause drug addiction.
In fact, migraine is a kind of headache with or without temporary disorders of the brain and plant nervous system due to episodes of vasodilator instability and temporary changes of certain humoral substances. It is a common disorder that affects approximately one in 10 people and is therefore listed by the World Health Organization as one of the 20 lifelong disorders that seriously affect human life and work. In addition, women are about twice as likely as men to suffer from migraines. It is rare to have a single type of migraine, but often several types of migraine or even other types of headache, such as tension-type headache, are present at the same time.
5.What are the manifestations of migraine?
Migraine is mainly manifested as episodic headache. The number of attacks per capita is about 13 times per year, and attacks in women often coincide with menstrual periods. Each attack can last from 4 hours to 2 days, but usually lasts more than 10 hours. The main manifestations are as follows.
(1) Severe throbbing headache. If you touch your pulse with your hand, you can feel the head throbbing pain one after another with the rhythm of arterial pulsation. Most of the pain is located on one side of the head, but it can also be a bilateral headache. Some patients think that migraine must be a unilateral headache because of the misunderstanding of the name of the disease.
(2) Hypersensitivity to strong light, loud and sharp noises, and some smells, often wanting to be alone in a quiet, dark place.
(3) Nausea and vomiting.
(4) The headache worsens when walking, especially when going up and down stairs.
(5) Some patients may experience visual abnormalities before or during an attack, such as flashes of light, jagged patterns, or dark spots in the visual field. The visual abnormalities that appear before a headache attack are called the “aura” of migraine.
6.What are the causes of migraine? What are the triggers?
To date, the exact cause of migraine is not known. First of all, it is thought that the disease is genetically predisposed because there are often multiple migraineurs in the same family. Second, it is now known that during a migraine attack, the level of a chemical in the patient’s brain called 5hydroxytryptamine (also known as serotonin) decreases, causing abnormalities in cerebrovascular function and dysregulation of other chemicals in the brain, resulting in symptoms such as headaches. In addition, a number of factors can induce migraine attacks, called migraine triggers, the common ones are.
(1) Strong flashes of light, such as prolonged gazing at a television, computer screen, or other video display device
(2) Constant, sharp noise
(3) Smoking, or inhaling tobacco, spices, and other odors
(4) changes in sleep rhythms, such as sleeping, staying up late, night shifts
(5) excessive fatigue, including physical or mental exertion
(6) Eating less, or too long between meals, such as skipping breakfast, etc.
(7) certain foods, such as red wine, cheese, smoked fish, bacon, chicken liver, hot dogs, chocolate, nuts, etc.
(8) lack of water in the body
(9) Endocrine disorders, such as puberty, menstruation, oral contraceptives, menopause, hormone replacement therapy, etc.
Migraine is an individualized disease, and each patient’s attack may be related to one or several of the above triggers, or may be triggered by other triggers.
7.How to treat migraine?
The treatment of migraine includes both the treatment during the attack and the treatment between attacks.
As soon as the manifestation of an attack or even an aura appears, you should take pain medications such as painkillers, paracetamol tablets, Benadryl, or over-the-counter (OTC) medications such as Tylenol. These medications are available in street pharmacies and can be carried with you for emergency purposes. If vomiting occurs at the same time, you should also take anti-emetic medications such as Gastrofacial to prevent the pain medication from being vomited out and not being effective. These medications are indicated for mild to moderate migraine attacks.
If the above-mentioned drugs do not work well and the headache is heavy, you can use the drugs of the class of treprotan, which are currently used clinically in China, such as sumatriptan (Yingminger, Yusu) and zolmitriptan (Zomig), and rizatriptan which is under clinical trial. These drugs can regulate the imbalance of 5hydroxytryptamine in the brain, and are effective drugs for migraine attacks, but they need to be taken with a physician’s prescription and are expensive. It is suitable for patients with severe attacks but infrequent attacks. The headache usually disappears within 2 hours with proper rest after taking the above drugs.
Patients with intermittent attacks usually do not need medication, but for patients with frequent attacks, such as more than 3 attacks per month, migraine attack prevention medication should be taken to reduce the frequency of attacks. Commonly used migraine prevention medications include beta-blockers and antidepressants (amitriptyline, etc.) that require a physician’s prescription. Patients with frequent attacks should not take commercially available painkillers frequently on their own to avoid rebound headaches.
8.How to prevent migraine attacks?
Migraine attacks are related to certain triggers, so identifying and avoiding these triggers in daily life can help reduce the frequency of headache attacks. Patients can also take the following measures.
(1) Keep a migraine diary. The contents include the time of headache attacks, the effect of medication, and possible triggering factors. By analyzing the attacks and the pre-injury living and eating conditions, the triggers of migraine can be identified.
(2) Avoid these triggers in daily life, such as flashing lights, noise, etc.
(3) When you have to use computer or other video display devices for a long time, pay attention to rest at work.
(4) Drink more water and less alcoholic or caffeine-containing beverages.
(5) Maintain a regular sleep.
(6) Outdoor activities, fresh air, exercise.
(7) Eat regular and moderate meals. Avoid foods that may trigger headache.
Through proper treatment and lifestyle adjustment, migraine patients can reduce the attacks of headache and alleviate the pain during the attacks, thus improving their quality of life.
9.What is tension-type headache?
Tension-type headache is the most common type of headache among adults, and its onset is related to psychosocial stress, anxiety, depression, mental factors, muscle tension, and abuse of pain medication. The disease is most common in adults, especially in women. The duration of the disease is mostly long, lasting for decades, and often recurrent, with milder cases occurring only when there is significant tension or depression, and chronic cases lasting for days or weeks. It usually presents as a persistent bilateral occipital or frontal dull pain that may extend to the entire head, often with a feeling of heaviness of pressure or tightness around the head, although sometimes there may be mild dizziness, blurred vision or tinnitus, but rarely nausea, vomiting or general discomfort. Tension and apprehension can trigger the disease.
10.What are the clinical manifestations of tension-type headache?
Typical cases usually start around 20 years old, and the prevalence increases with age; both sexes can be affected, but it is more common in women. It is characterized by almost daily bilateral occipital non-pulsating headache, also known as chronic daily headache. It is usually a persistent, dull pain that resembles a band around the head or a sensation of constriction, pressure or heaviness around the head, without prodromal symptoms such as nausea, vomiting, photophobia or phonophobia, or visual disturbances. Many patients may experience dizziness, insomnia, anxiety or depression. Or it may be a more frequent headache, and daily life is not affected during the headache. There may be tenderness or pressure points in the muscles of the painful area, and sometimes there is pain when pulling the hair; there is stiffness in the muscles of the back via the shoulder, and the muscles feel comfortable when pinching and pressing. Traditionally, tension-type headache and migraine are considered to be different diseases, and some cases have the headache characteristics of both, and some patients with tension-type headache may have throbbing headache, one-sided headache or vomiting during the attack. Therefore, it may be more correct to consider tension-type headache and migraine as representing opposite poles of a clinical disease spectrum.
11. How is tension-type headache treated?
Many of the drugs used to treat this disease are the same as those used for migraine. Acute attacks are effectively treated with acetaminophen, aspirin, nonsteroidal anti-inflammatory drugs, ergotamine or dihydroergotamine. Prophylactic treatment with amitriptyline, promethazine, or selective 5-hydroxytryptamine reuptake inhibitors (e.g., lindane or clostebol) is often effective, and promethazine is useful in some cases. Those with insomnia may be given benzodiazepines such as diazepam 10-20 mg/d orally. Stellate ganglion block is effective for tension-type headache, but needs to be adhered to.
12.How to prevent tension-type headache attack?
(1) Pay attention to keeping warm in the morning and evening, and pay attention to the increase or decrease of clothes in the morning, midday and evening.
(2) Pay attention to eating more sour and sweet things that nourish yin, such as tomatoes, lilies, green vegetables, strawberries and oranges, and avoid eating spicy and greasy foods.
(3) Adjust your emotions, don’t give yourself too much pressure, don’t bury your head in books all day and night, get out of the house more often to exercise outdoors, try to relieve and relax your emotions
13.What is cluster headache?
Cluster headache is also called migraine neuralgia, histamine headache, rock neuralgia, pteropalatine neuralgia, Horton’s headache and so on. Patients have a series of severe headaches that appear suddenly at a certain period of time, usually without aura. The pain is mostly found in one orbital or (and) frontotemporal region, and may be accompanied by ipsilateral conjunctival congestion, tearing, eyelid edema or nasal congestion, runny nose, and sometimes narrow pupils, droopy lids, flushing, and swollen cheeks. The headache is mostly non-pulsating and severe, and the patient fidgets or shakes forward and backward, and some patients punch their heads to relieve the pain. Many patients have headaches that occur at a fixed time, with each attack lasting 15 to 180 minutes, and will resolve on their own. Sequences of attacks last from 2 weeks to 3 months (called clusters), and many patients have clusters that occur in the same season of the year. Intermittent periods last from several months to several years, during which symptoms resolve completely. About 10% of patients have chronic symptoms.
The disease is most common in young people (20-40 years old), 4-7 times more common in men than in women, and there is usually no family history. When headache attacks with analgesic tranquilizers are not effective, oxygen inhalation (with mask, 10 l/min, not less than 15 minutes) or intranasal drops of 2% lidocaine can be applied. Injections of 6mg subcutaneously can also be used. Corticosteroids, lithium carbonate, ergotamine or calcium channel blockers can be used to prevent and shorten the clustering period. Prednisone (start with 40-60mg/d and reduce after 10 days) is more effective and can shorten or abort the cluster phase. Lithium carbonate (600mg/d) is available for chronic cases.
14.What are the clinical manifestations of cluster headache?
The headache of this disease is characterized by a series of headache attacks that seem to come in clusters, which are characterized by a series of intensive headache attacks. The attacks are periodic and have no antecedent symptoms. The pain starts around the eye sockets on one side and extends rapidly to the frontal-temporal region, and may involve the opposite side in severe cases. The pain is pulsating, accompanied by a drilling or burning pain, and may awaken during sleep. The characteristic concomitant symptoms include facial flushing, sweating, tearing on the affected side, conjunctival congestion, and nasal congestion. In addition to superficial temporal artery anger, there is also incomplete Horner’s syndrome such as narrowing of the affected pupil and drooping eyelids.
The attacks can occur one to two times a day, with each attack lasting about tens of minutes to two to three hours, and disappear quickly with a long remission time. Patients rarely experience posterior fatigue or drowsiness, and the headache occurs regularly at approximately the same time each day, often in the late afternoon or early morning. Headache attacks can be triggered by alcohol or nitroglycerin consumption. The headache is often confined to the same side.
15.How to treat cluster headache?
Analgesics and tranquilizers are not effective during headache attacks. Oxygen (100% oxygen 8~10L/mim, 10~15min); sumatriptan or dihydroergotamine can rapidly relieve headache; prednisone 40~60mg/d orally for 1 week, dramatic improvement is typically seen. Pain may subside within a few hours, mostly within 2 d. Taper off and stop in the 2nd week
Relapse prevention during seizures: mexigargin 2-8 mg orally once/d; calcium antagonist (isobodine extended-release type).
Prevention of nocturnal attacks: rectal suppository of ergotamine & subcutaneous injection of dihydroergotamine at bedtime. Stellate ganglion block can be used in pain department to relieve painful episodes; pterygopalatine ganglion block or destruction can also be considered if necessary.