Headache

Headache (cephalgia) is widespread. During the year, at least once occurs in 90% of people. In 95-98% of cases, it develops in the absence of organic pathology. Symptomatic (secondary) cephalgia can bother people of any age and gender, more often appear in representatives of older age groups, which is associated with the widespread prevalence of vascular pathologies, the presence of previously transmitted provoking diseases. The occurrence of various primary cephalgias correlates with the gender of patients.

There are no pain receptors directly in the brain tissues, therefore, irritation of neighboring structures becomes a factor causing the occurrence of pain: meninges, cranial and spinal nerves, nociceptors in the walls of extracranial vessels, muscles of the head and neck against the background of compression, muscle tension, changes in the tone of arteries and veins, etc. The causes of primary headaches have not yet been definitively clarified. Most experts assume that such cephalgias develop as a result of complex changes in nerves and blood vessels.

Rare or single cephalgias that occur against the background of external influences and do not entail a threat to health are considered as physiological. The remaining options are considered pathological. Taking into account the presence or absence of provoking diseases, all headaches are divided into primary and secondary. There are the following causes of secondary cephalgia:

Depending on the localization, pain is isolated in the entire head, its right or left half, the back of the head, crown, temples. In some cases, the pain syndrome migrates or occurs in one zone, and then spreads to neighboring ones.

Episodic single or rare cephalgia can be observed in the following circumstances:

Other possible causes are mental or physical fatigue, hunger, adherence to strict diets, taking a large amount of strong tea and coffee, or, on the contrary, a sharp rejection of caffeinated drinks with the habit of drinking them.

Despite the absence of an organic basis, they appear regularly, often differ in high intensity, worsen the quality of life, negatively affect the ability to work:

Cephalgia accompanies all traumatic brain injuries. The pain is diffuse, can be pressing, bursting, moderate or intense. They are amplified in the standing position and during movements. Combined with dizziness, nausea, vomiting, neurological disorders. The duration depends on the severity of the injury. With a concussion, pain persists for 2-3 weeks, with a bruise – 1-2 months or more.

Vascular diseases

The most threatening condition that causes a headache of vascular genesis is hemorrhagic or ischemic stroke. Cephalgia occurs suddenly, accompanied by rapid deterioration, weakness, nausea, vegetative symptoms. Then paresis, disorders of consciousness, speech disorders develop. Other pathologies include:

• PNMC. Headaches are the same as before a stroke, but all symptoms disappear within a day.
• Cerebral atherosclerosis. Worries about soreness in the back of the head or spilled cephalgia during emotional and physical exertion, memory loss, sleep deterioration, asthenia.
• Hypertension. The pain is diffuse, pulsating, bursting with an epicenter in the area of the occiput or forehead.
• Hypotension. Painful sensations are bursting, dull, complemented by a feeling of heaviness in the head, weakness, dizziness.
• Vegetative-vascular dystonia. Blunt compressive pains are typical, less often – burning bursting pains, combined with numerous vegetative symptoms.
• Vertebrobasilar insufficiency. There is a sharp unilateral pain in the back of the head after awkward neck movements with irradiation to the temple, forehead and eye. Falls, vegetative disorders are possible.
• Horton’s disease. The pain syndrome is caused by a lesion of the temporal artery, is localized in the temple area, is initially aching, then burning, increases when talking and chewing.

Non-vascular intracranial lesions

The most common cause of this group of cephalgias is intracranial hypertension. The pain is symmetrical, diffuse, more pronounced in the crown of the head and forehead. With a rapid increase in the pressure of the cerebrospinal fluid – intense, progressive, with chronic disorders – moderate, dull, wavy or constant. Possible provoking conditions are:

• Volumetric formations: primary neoplasia, brain metastases, abscesses, hematomas, cysts.
• Brain edema: aseptic and carcinomatous meningitis, aseptic arachnoiditis.
• Cerebrospinal fluid disorders: hydrocephalus of various genesis.

In addition, this group includes headaches with a decrease in cerebral pressure (with cerebrospinal fistulas, after spinal puncture), epileptic seizures, direct compression of the meninges by neoplasms.

Infectious diseases

Headache is caused by the following infectious lesions of cerebral structures:

• Meningitis. It is more pronounced in the back of the head, spreads throughout the head. It increases rapidly, supplemented by chills, fever, nausea, vomiting, pronounced weakness, meningeal symptoms.
• Encephalitis. It occurs acutely, progresses rapidly, covers the entire head, combined with severe intoxication. Convulsions, disturbances of consciousness, mental disorders are possible.
• Brain abscess. Along with a spilled headache, intoxication is observed. Focal symptoms of varying severity, epileptiform seizures are noted.
• Empyema. Manifests with cephalgia and severe hyperthermia. Nausea, vomiting, meningeal symptoms are observed. Later, a neurological deficit joins.

Minor or moderate aching, pressing prolonged headache may be associated with infectious-toxic syndrome in influenza, acute respiratory viral infections, and other common infections. Respiratory tract diseases (pneumonia, tracheitis, bronchitis) can also be the causes or the urinary system (pyelonephritis, glomerulonephritis). Cephalgia is observed in some local purulent processes: abscesses and phlegmon of soft tissues, hydradenitis, carbuncle. Accompanied by erysipelas of the scalp.

Neuralgia

Occipital neuralgia provokes pain in the back of the head. It proceeds in the form of excruciating pain paroxysms, more often bothers on the one hand, gives in the neck and ears. With trigeminal neuralgia, attacks of intense burning or shooting pains in the temple are possible, spreading to half of the face. The duration of paroxysm in both cases ranges from a few seconds to 2 minutes, episodes can be repeated many times during the day.

Intoxication and withdrawal of drugs

Cephalgia most often develops against the background of the following intoxications:

• Alcohol intake. As a rule, the cause is a hangover. The pain can be minor, dull or severe, sharp, pulsating. Sometimes the symptom occurs immediately after drinking alcohol.
• Food poisoning. The headache is not intense, aching in nature, combined with abdominal pain, nausea, diarrhea.
• Carbon monoxide poisoning. There are moderate spilled aching pain sensations, sometimes – in combination with stupidity, uncriticism to their behavior.

Psychoactive substances capable of provoking the symptom include nicotine, hashish, cocaine and opiates. An abusive headache develops with prolonged use of painkillers. Other drugs that can cause cephalgia are ergotamine, histamine-containing drugs, some hormones, phosphodiesterase inhibitors. Pain syndrome can be observed with the withdrawal of estrogens, opiates, and other medications.

Homeostasis disorders

A heterogeneous group of pathologies associated with a violation of the constancy of the internal state of the body: oxygen starvation, overheating, etc. Includes:

• hypoxia, hypercapnia;
• caisson disease;
• heat and sunstroke;
• respiratory disorders in sleep apnea;
• preeclampsia and eclampsia;
• hypothyroidism, pheochromocytoma;
• coronary heart disease.

Pathologies of neighboring structures

Cephalgia can accompany the following diseases of nearby organs and tissues:

• Otolaryngological: frontitis, pansinusitis, acute otitis media, mastoiditis, Tornwald cyst, purulent labyrinthitis.
• Ophthalmological: myopia, hyperopia, strabismus, acute glaucoma.
• Dental: TMJ dysfunction on the background of malocclusion, injuries, defects of dentition, bruscism, overload of masticatory muscles.
• Vertebrological: osteochondrosis, intervertebral hernia, spondylosis, spondyloarthrosis.

Mental disorders

Complaints of dull bursting pains in the head can be made by patients with hypochondria, anxiety and depressive disorder. Patients with neurasthenia describe their feelings as “squeezing the head with a helmet.” With hysteria, the pain syndrome often has an unusual character, does not fit into the picture of a certain pathology. In patients with severe mental disorders, pain sensations are often unusual, pretentious, strange.

Diagnostics

Neurologists are engaged in determining the nature of pathology. According to the indications, consultations of a therapist, an infectious disease specialist and other specialists are prescribed. As part of the survey, they find out complaints and life history, establish the circumstances of the appearance and features of headache, the dynamics of the development of the disease. During an external examination, signs of TBI and intoxication syndrome are detected, hypotension or hypertension is detected by measuring blood pressure. To clarify the diagnosis , the following procedures are performed:

• Neurological examination. The aim is to detect focal neurological symptoms, meningeal symptoms and other manifestations indicating a central nervous system lesion. The doctor examines reflexes, sensitivity and muscle strength, conducts special tests.
• Radiography. An X-ray examination of the skull is prescribed to detect fractures of the base and arch. When finger indentations and osteoporosis of the back of the Turkish saddle are detected, it indicates chronic intracranial hypertension. If a pathology of the solid structures of the neck is suspected, radiography of the cervical spine is required.
• EEG. It is performed to assess the functional activity of the brain. Confirms the foci of epiactivity in epilepsy, makes it possible to suspect bulky formations (abscesses, tumors, hematomas). If necessary, it is performed with functional tests.
• Ultrasonography. Echoencephalography in TBI detects the presence of displacement of median structures, hydrocephalus, brain edema. Duplex examination and Dopplerography are indicated for suspected vascular character of cephalgia, reveal circulatory disorders.
• Tomography. CT and MRI of the brain are carried out at the final stage of the examination, helping to clarify the data obtained during other diagnostic procedures. They allow to evaluate the structure of tissues, to detail information about the location and features of focal changes. They can be native and contrasting. The second option is recommended for tumors and vascular pathologies.
• Lumbar puncture. It is performed for hydrocephalus, infectious and inflammatory lesions of the brain, TBI. Confirms an increase or decrease in intracranial pressure, the presence of inflammation and bleeding. According to microscopy and PCR of the cerebrospinal fluid, the composition of the punctate is studied, pathogens are detected.
• Laboratory tests. They are carried out to assess the general condition of the body, diagnose infectious and inflammatory pathologies, atherosclerosis, metabolic disorders, intoxication.

Treatment

Conservative therapy

Therapeutic tactics are determined taking into account the etiology of headache:

• Primary cephalgia. Combined painkillers, triptans, NSAIDs are recommended. With intense pain, narcotic analgesics are indicated. In some cases, therapeutic blockades are effective.
• Vascular pathologies. Treatment of atherosclerosis and arterial hypertension is carried out using hypolipidemic and hypotensive drugs, diuretics, beta-blockers, disaggregants. With VSD and hypotension, adaptogens, antidepressants, tranquilizers, antioxidants, vitamin complexes are prescribed. Acupuncture, massage, hydrotherapy, aromatherapy are used.
• Infectious diseases. Antibiotics are administered parenterally. The plan of symptomatic therapy is made taking into account the existing disorders. Infusions of solutions are carried out, resuscitation measures are performed according to indications, vital functions are maintained using ventilators and medicines, monitoring is carried out.
• Intoxication and general infections. In the first case, antidotes are used, in the second, etiopathogenetic therapy is prescribed. Patients of both groups need detoxification measures: copious drinking, infusion of crystalloid and colloidal solutions, enterosorbents, stimulation of diuresis. The list of measures is determined by the patient’s condition.
• Neuralgia. The basic drugs are anticonvulsants. The therapy plan is supplemented with antihistamines, microcirculation correctors, antispasmodics. Medical blockades are carried out.

Patients with diseases of neighboring structures require treatment with the participation of an otolaryngologist, ophthalmologist or dentist. The program may include analgesics, antibiotics, vasodilators, etc. Patients with tumors are indicated for radiation therapy or chemotherapy.

Surgical treatment

Depending on the existing pathology , the following operations are performed:

• Vascular diseases: carotid endarterectomy, creation of extra-intracranial anastomoses, prosthetics of the brachiocephalic trunk, removal of hematomas, ventricular drainage.
• Hydrocephalus: removal of neoplasms and abscesses, decompressive trepanation of the skull, external ventricular drainage, various bypass options.
• TBI: removal of depressed fractures, decompressive trepanation, minimally invasive and open removal of hematomas.
• Neuralgia: stereotactic operations, microsurgical decompression, radiofrequency destruction.
• ENT diseases: sanitizing intervention on the middle ear, bypass surgery of the tympanic cavity, mastoidotomy, open and endoscopic variants of polysinusotomy and frontotomy.

Literature

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