I. Headache caused by intracranial lesions The pain is more intense, mostly deep swelling and cracking pain, often accompanied by vomiting, signs of neurological damage, convulsions, impaired consciousness, mental anomalies and even changes in vital signs to varying degrees. (I) Meningoencephalitis is a meningeal irritation headache, with pain in the neck and neck area and signs of meningeal irritation. The onset of the disease is usually rapid, with fever and positive cerebrospinal fluid. (B) Cerebrovascular disease 1, hemorrhagic cerebrovascular disease: cerebral hemorrhage is often associated with severe headache, but not headache. Those with headache as the main complaint are subarachnoid hemorrhage, which is often missed due to the absence of signs of neurological limitation such as hemiparesis. The disease is characterized by sudden onset of severe headache after exertion or emotional stress, vomiting, and meningeal irritation. The causes are mostly congenital aneurysms, arteriovenous malformations and cerebral arteriosclerosis. Blood old hemorrhagic cerebrospinal fluid can confirm the diagnosis. 2, ischemic cerebrovascular disease: cerebral thrombosis is generally rare headache, but a transient ischemic attack headache of vertebral basilar artery is not uncommon, the following can be used as a diagnostic basis: ① headache can be induced by head rotation or upright position. ② Headache before and after or at the same time with other brainstem transient ischemic symptoms, most commonly vertigo, others may be flash of light and dark spots, black haze, diplopia, numbness of the mouth and face, pain in the ear, vision distortion. (iii) There may be mild signs of brainstem damage, such as nystagmus (more likely to occur after the patient tilts his head back and turns his neck, so that one side of the vertebral artery is compressed), retardation or disappearance of one side of the corneal reflex or (and) the pharyngeal reflex, balance disorders, or positive pathological reflexes. ④ There is a clear etiology, such as cerebral arteriosclerosis, diabetes mellitus, coronary artery disease, as well as hyperplasia, trauma or deformity of the cervical spine. ⑤ Positive laboratory tests such as cerebral hemogram (wave amplitude decrease of 30% or more after tilting the head back and turning the neck), Doppler ultrasonography of the vertebral arteries in the extracranial segments (narrowing of the canal diameter or/and decrease in blood flow), and nystagmus electrography (nystagmus appears after turning the neck). The mechanism of ischemic cerebrovascular disease headache may be due to insufficient intracranial blood supply, extracranial vascular compensatory dilatation, therefore, it also has the characteristics of vascular headache. Cerebral arteriosclerosis: it is caused by the lack of oxygen in the brain. The headache is mostly accompanied by neurasthenia, and those with high blood pressure are characterized by hypertensive headache and signs of minor neurological damage, atherosclerotic signs in the fundus of the eye and the heart, and elevated blood lipids. 4, hypertensive encephalopathy: hypertensive patients such as sudden rise in blood pressure and lead to small arterial spasm in the brain when acute cerebral edema occurs, acute intracranial pressure can be increased and produce severe headache, fundus can be seen in the retinal arterial spasms, hemorrhage, oozing and so on. It is mostly seen in uremia and eclampsia, etc. (C) Intracranial mass and increased intracranial pressure, including brain tumor, brain abscess, intracranial hematoma, cyst (arachnoiditis), brain parasites and so on. On the one hand, the swelling itself on the intracranial pain-sensitive tissues of the pressure, push, can cause local and neighboring parts of the headache (traction headache), such as pituitary tumors can produce bitemporal or post-ocular distension, headache was progressive aggravation, and neurological limitations of the signs; on the other hand, 80% of the patients with the swelling have increased intracranial pressure, the whole head showing distension, blast pain, slow onset of the early morning after the occurrence of the person (due to) After lying down overnight, cerebral venous depression, intracranial pressure increases even more), and then gradually for persistent pain, after coughing, exertion due to the sudden increase in cranial pressure, headache aggravation, and vomiting, optic papillary edema, retinal hemorrhage, psychiatric symptoms, epilepsy and so on. See Section V for details. (D) Low cranial pressure syndrome Mostly occurs after lumbar puncture, craniocerebral injury, surgery or meningoencephalitis, etc., as well as severe dehydration, etc. The pressure of lumbar puncture cerebrospinal fluid in the lateral position is below 0.59-0.78 kPa (70-80 mm water column), or it cannot flow out at all. Sudden severe headache after sitting up, often accompanied by nausea, vomiting, the Department of so the intracranial pressure drops further, the intracranial pain-sensitive tissues lose the cerebrospinal fluid support and pulling caused by, so also belong to the traction headache. The headache is rapidly relieved after lying down. Occasionally, there may be elevated pulse and blood pressure. (E) epileptic headache, mostly seen in adolescents and children, headache is a severe throbbing pain or explosive pain, seizure and termination are more sudden, for a few seconds to tens of minutes, occasionally up to a day, seizure frequency varies. It may be accompanied by nausea, vomiting, dizziness, runny eyes, tears, abdominal pain, impaired consciousness or terror. EEG examination, especially in the seizure into often have epileptic waveforms, may also have a history of other types of epileptic seizures, family history of epilepsy and related etiology history, taking antiepileptic drugs can control seizures. It may be caused by abnormal discharges in the mesencephalic region due to various diseases. (Headache after craniocerebral injury Early headache in craniocerebral injury is related to soft tissue injury, cerebral edema, intracranial hemorrhage, hematoma, and infection. Headache in the later stage is quite common, and most of them are debilitating manifestations called “traumatic neurosis” or “post-traumatic brain injury syndrome”. However, a large proportion of patients have other headache manifestations, either concurrently or separately, and the mechanism is also very complex. Commonly, there are vascular headache (including various types of migraine-like vascular headache), muscle contraction headache, cranial surface neuralgia, and headache caused by scalp scars. It is related to the damage of local blood vessels, vasomotor center, scalp, cervical muscles, cervical nerve roots or nerve branches in the head and neck, and some of them are related to the transient ischemia of vertebral artery caused by concurrent cervical spine injury. A few headaches are caused by late complications of trauma, such as intracranial hematoma, traumatic cerebral arachnoiditis, low cranial pressure syndrome, spontaneous pneumocephalus, epileptic headache, and late-onset brain abscess and meningitis. Therefore, a detailed history should be asked and relevant examinations should be performed to clarify the nature and type of headache, and it is not appropriate to diagnose the sequelae of traumatic brain injury without analysis. Headache caused by extracranial head and neck lesions (a) The most important and common type of headache is vascular headache, which is characterized by throbbing pain or distending pain consistent with pulse. Headache may be aggravated by lowering the head, heat, exertion and coughing. Examination of the temporal artery can be seen bulging, pulsation enhancement, headache can be reduced after compression. It can be divided into two categories: 1. Migraine class: all of them are acute recurrent attacks, and accompanied by some specific symptoms. (1) Migraine: often onset in adolescence, some patients have family history, mostly induced by exertion, emotional factors, menstruation and so on. Typical (ophthalmic migraine) headache attacks are preceded by ocular aura, such as flashing light, black haze, foggy vision, hemianopsia, etc., and there may also be numbness of the face, tongue, limbs, etc., which is related to intracranial vasospasm. About 10-20 minutes later, followed by extracranial vasodilatation, one or both sides of the intense throbbing pain or distension, mostly accompanied by pallor, cold limbs, drowsiness, etc., and may have mood and behavioral changes; headache to the peak of the nausea, vomiting, and lasts for a few hours to a day to recover. The frequency of attacks varies. Those without the above aura are called “common type migraine”. It is more common, and the attacks can last for several days. A small number of headache recurrent episodes after the emergence of a transient palsy of the motor eye nerve is called “ophthalmic muscle paralysis type migraine”, but the onset of a long period of time after the ophthalmic muscle paralysis no longer recovered. The pathogenesis of this disease is complex, and in recent years, we tend to think that after the triggering factors act on the central nervous system, the monoaminergic pathway produces neurotransmitter changes, followed by the activation of platelets to cause the release and depletion of 5-HT and thromboxane A2 (TX A2), and then produce intracranial and extracranial vasoconstriction and dilatation of the vascular expansion of the wall of the dilatation of the tube due to the adsorption of 5-HT to produce vasoresponsiveness, coupled with the participation of histamine, bradykinin, etc., the headache and its neurovascular response occur. and its neurovascular reaction. (2) Cluster headache: It is common in adult males, with dilatation of both intracranial and extracranial blood vessels during the attack, and throbbing pain mainly in the periorbital region on one side, accompanied by runny nose, nasal obstruction and facial congestion on the side of the headache, which lasts for about half an hour to two hours and is relieved, and it is often seen in the same form at the same time of the day for many times, and it can occur in the night time as well. The attacks last from a few weeks to 2-3 months and then gradually diminish, abate and cease. However, similar cluster-like attacks recur after an interval of several weeks or years. The etiology is also not completely understood. Some may be related to allergic reactions, trauma, pterygopalatine ganglion or Iwata superficial neuropathy. (3) Cervical migraine: related to cervical spine trauma or hyperplasia. The symptoms are similar to migraine, but the headache is accompanied by symptoms of brainstem ischemia produced by spasm of the vertebral artery, such as vertigo, pain in the ear, foreign body sensation in the pharynx, dysphagia, etc., as well as symptoms of cervico-thoracic nerve root irritation, such as numbness, pain, and weakness of the upper extremity on the side of the headache. With the recovery of the headache, all the above symptoms also disappear. In the intermittent period, there may be limited neck activity, cervical muscle pressure and some signs of cervicothoracic nerve root damage, and some of them have mild persistent headache. 2, non-migraine headache: no obvious episodic and specific accompanying symptoms. Most of them are caused by systemic diseases that expand intracranial and extracranial blood vessels, such as infection, poisoning, hyperthermia, hypertension, hypoxia (cerebral blood supply insufficiency, cardiopulmonary insufficiency, anemia, plateau reaction) and hypoglycemia, etc. There are always signs of primary disease that can be seen in the headache. The diagnosis can be made on the basis of the symptoms of the primary disease. In addition, there is temporal arteritis, mostly seen in middle-aged and elderly men, partly related to colitis. At the beginning of the disease, the gums, occipital neck pain, followed by temporal throbbing pain, temporal artery hardening, pressure, flexion and nodular, local skin redness, erythema, and emaciation, fever, leukocytes and blood sedimentation rate increase and other systemic symptoms. When the lesion involves the ophthalmic and intracranial arteries, visual impairment and other neuropsychiatric symptoms may occur. Some of the disease can be cured spontaneously, but hormone therapy should still be used early. (II) Head and neck neuritis headache Occipital nerve, supraorbital nerve and auriculotemporal nerve, etc., can cause neuralgia of head nerves due to cold, infection or trauma. The first branch of the trigeminal nerve can also be infected, cold, etc., causing persistent or accompanied by briefly aggravated episodes of pain in the front of the head, called trigeminal neuritis or symptomatic trigeminal neuralgia. See Chapter V, Section I for details. (C) Headache caused by skin, muscle and skull lesions of the head and neck 1. Acute infection of the scalp, boils and tumors of the skull can cause local headache. The primary lesion is obvious and the diagnosis is not difficult. 2, tension headache (muscle contraction headache): quite common. It is caused by the continuous contraction of head and neck muscles, and is mostly a persistent dull pain in the front head, occipital neck or the whole head. The cause of most of the mental tension or anxiety, can also be secondary to vascular headache or headache of the five senses, sometimes for the head and neck myositis, cervical muscle strain or cervical spondylosis. (D) headache caused by five senses and oral lesions Headache is caused by the spread of pain from the original focal site, is “involved headache”. There are obvious signs of the original disease. When the signs are not obvious, such as mild refractive error, chronic glaucoma, etc., it is easy to miss the diagnosis. 1, nasal lesions (1) paranasal sinusitis: headache is always accompanied by nasal obstruction, runny nose and local pressure. In addition to the butterfly sinusitis headache can be in the deep part of the head or the back of the ball, the other more to the sick sinus parts. The degree of headache is often related to the drainage of paranasal sinuses, so the frontal sinusitis headache is heavy in the morning, and gradually reduced after standing for a long time, while the upper stool sinusitis is vice versa. Nasal septal deviation can be due to damage to the nasal turbinate, similar to the maxillary sinus for the headache. (2) Cancer of nasopharyngeal cavity: in addition to headache, there are epistaxis, pus, multiple cranial nerve palsy (due to filling of Eustachian tube, deafness is conductive!) and cervical lymph node metastasis. and cervical lymph node metastasis. Biopsy of the nasopharyngeal cavity confirms the diagnosis. A few symptoms are atypical, should be repeated nasopharyngeal cavity biopsy for early diagnosis. 2, eye lesions (1) refractive error (hyperopia, astigmatism, presbyopia) and eye muscle balance disorders: headache is mostly a dull pain, can be accompanied by eye pain and eye distension, aggravated by reading, and can be read in the wrong line or into the phenomenon of double line, after a long time there can be a neurasthenia performance. (2) glaucoma: pain in the affected eye to the main expansion of the sick side of the forehead, acute often accompanied by vomiting, vision loss, corneal edema, clouding, etc.; chronic with the physiological expansion of the optic papillary depression. Measurement of intraocular pressure can clarify the diagnosis. (3) Acute infection of the eye: also often cause severe headache, but the local signs are obvious, it is not easy to miss the diagnosis. Acute otitis media and mastoiditis can cause severe earache and headache on one side of the head, which is mostly throbbing. 4, oral lesions, toothache can sometimes extend to the side of the pain. Temporomandibular joint pain often extends to one side of the headache from the localization, joint pain during biting, and local pressure pain. Third, headache caused by somatic diseases other than head and neck headache mechanism and its causes can be broadly divided into three categories: ① non-migraine vascular headache: the disease in the front. ② traction headache: seen in cardiac insufficiency, emphysema, etc., due to intracranial venous depression, causing mild brain swelling. (iii) neurasthenia headache (neurasthenia syndrome): seen in chronic infections (tuberculosis, hepatitis, pediatric intestinal parasitosis, etc.) and endocrine metabolic disorders (hyperthyroidism, menopause, etc.). Fourth, neurosis and psychiatric headache caused by the most common clinical cause of headache is neurasthenia, but must be excluded in the above various organic diseases and have a clear manifestation of neurasthenia, before diagnosis. Headache may be related to the lowering of the tolerance threshold for pain, but there are patients with headache characterized by vascular headache or muscle contraction headache due to vascular dysfunction or stress. Anxiety headaches are most often accompanied by marked manifestations of anxiety. Depressed patients also often have headache, depression symptoms are ignored, should be highly vigilant. Dysthymic headache is more indeterminate, variable in nature, and there are other dysthymic manifestations, such as the onset of emotional factors as well as other kinds of physical discomfort. Sometimes there can be acute headache attacks, exaggerated symptoms, often crying, rolling, calling, in addition to sporadic sensory deficits and bilateral hyperreflexia, physical examination and the nervous system without other abnormalities. When the history and physical examination to attract their attention, the headache can be significantly reduced, suggesting that the treatment can be quickly cured. Headache can also be present in severe psychosis, but it is rarely the main complaint of headache.