Text 17 Headache

Headache is such a common complaint and can occur for so many different reasons that its proper evaluation may be difficult. Chronic headaches are commonly due to migraine, tension, or depression, but they may be related to intracranial lesions, head injury, cervical spondylosis, dental or ocular disease, temporomandibular joint dysfunction, sinusitis, hypertension, and a wide variety of general medical disorders. Although underlying structural lesions are not present in most patients presenting with headache, it is evertheless important to bear this possibility in mind. About one-third of patients with brain tumors, for example, present with a primary complaint of headache.

The intensity, quality, and site of pain – and especially the duration of the headache and the presence of associated neurologic symptoms – may provide clues to the underlying cause. Migraine or tension headaches are often described as pulsating or throbbing; a sense of tightness or pressure is also common with tension headache. Sharp lancinating pain suggests a neuritic cause; ocular or periorbital icepick-like pains occur with migraine or cluster headache; and a dull or steady headache is typical of an intracranial mass lesion. Ocular or periocular pain suggests an ophthalmologic disorder; bandlike pain is common with tension headaches; and lateralized headache is common with migraine or cluster headache. In patients with sinusitis, there may be tenderness of overlying skin and bone. With intracranial mass lesions, headache may be focal or generalized; in patients with trigeminal or glossopharyngeal neuralgia, the pain is localized to one of the divisions of the trigeminal nerve or to the pharynx and external auditory meatus, respectively.

Inquiry should be made of precipitating factors. Recent sinusitis or hay fever, dental surgery, head injury, or symptoms suggestive of a systemic viral infection may suggest the underlying cause. Migraine may be exacerbated by emotional stress, fatigue, foods containing nitrite or tyramine, or the menstrual period. Alcohol may precipitate cluster headache.

Temporomandibular joint dysfunction causes headache or facial pain that comes on with chewing; trigeminal or glossopharyngeal neuralgia may also be precipitated by chewing, and masticatory claudication sometimes occurs with giant cell arteritis. Cough-induced headache occurs with structural lesions of the posterior fossa, but in many instances no specific cause can be found.

The timing of symptoms is important. Headaches are typically worse on awakening in patients with sinusitis or an intracranial mass. Cluster headaches tend to occur at the same time each day or night. Tension headaches are worse with stress or at the end of the day.

The onset of severe headache in a previously well patient is more likely than chronic headache to relate to an intracranial disorder such as subarachnoid hemorrhage or meningitis. The need for further investigation is determined by the initial clinical impression.

A progressive headache disorder, new onset of headache in middle or later life, headaches that disturb sleep or are related to exertion, and headaches that are associated with neurologic symptoms or a focal neurologic deficit usually require cranial MRI or CT scan to exclude an intracranial mass lesion. Signs of meningeal irritation and impairment of consciousness also indicate the need for further investigation (cranial CT scan or MRI and examination of the cerebrospinal fluid) to exclude subarachnoid hemorrhage or meningeal infection. The diagnosis and treatment of primary neurologic disorders associated with headache are considered separately under these disorders.