A Simple Guide to Headache
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What is Headache?
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Headache is a very common complaint, not an illness.
It literally means pain in the head.
What are the Common Types of Headaches?
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Tension headache:
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as defined by the International Headache Society is characterised by:
1.bilateral location
2.pressing/tightening (non-pulsating) quality
3. mild to moderate in intensity
4. not aggravated by routine physical activity like walking or climbing stairs.
It is the most common headache and may be associated with contractions of head and neck muscles due to physical or mental stress. The headache is made worse by changes in the environment, drugs, or factors unique to the individual.
It can also be classified into 2 side types:
episodic (<>
chronic (> 14 days a month on average and <>
Treatment can be divided into:
pharmaceutical
non pharmaceutical
Pharmaceutial:
can be divided into acute and prophylactic.
In acute treament simple painkillers is usually effective.
In prophylactive treatment,antidepressants like amitriptyline usually help in the prevention of tension headache.
Medicines should always be given at low doses and titrated up to therapeutic doses to minimise side effects.
Non-pharmaceutical:
1. rest
2. removal of aggravating factors.
3. relaxation exercises
Migraine:
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is defined as a heavy throbbing pain usually over one side of the scalp, forehead and about the eye, caused by abnormally dilated blood vessels.
Migraine may be accompanied by nausea, vomiting or sensitivity to loud noises or bright lights.
It is also triggered by certain factors unique to the individual such as:
1.menstruation,
2.alcohol,
3.anxiety,
4.loud noises,
5.bright lights
A validated 3 items questionaire covering
1. disability
2. nausea
3. sensitivity to lights
should given to every patient to screen the severity of the migraine.
Treatment again is divided into:
phamaceutical
non-pharmaceutical.
Pharmacetical:
can be divided into acute and prophylactic.
In acute treament simple painkillers like paracetamol is usually effective in mild cases.
Non-steroidal anti-inflamatory drugs should be tried if paracetamol fails.
If NSAIDs are ineffective then migraine-specific drugs like triptans or ergotamine which act to constrict blood vessel should be tried.
In some cases anti-emetic drugs like stemetil to prevent vomiting is given together with the migraine medication.
In prophylactic treatment, the goals are to:
1. reduce frequency,severity and duration
2.improve function and reduce disability
3.improve responsiveness to treatment of acute attacks
Medicines used include:
betablockers
Calcium channel blockers
Serotonin receptor antagonists
Antidressants
Anticonvulsants
Angiotensin blockers
NSAIDs
Non-pharmaceuticals:
1.resting in a cool, dark and quiet room.
2.relaxation exercises
3.Solving the triggering factors also help.
4.Oestogen containing oral cotraceptives should avoided in menstrual migraine.
During pregnancy or lactation treatment should be non-pharmaceutical when possible. If necessary paracetamol is the safest drug for women during pregnancy or lactation.
Cluster headaches
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is defined as pain which occurs in runs with tearing pain over the forehead or behind the eye(s) with flushing of the face.
There are aura of stars,flashing lights etc associated with this headache.
The cause is beleived to be due to histamine release from ingestion of certain foods like cheese, seafood,alcohol etc.
It is more common in males.
Treatment is by
1.strong painkillers
2.avoidance of food triggers
3.rest.
What are Secondary headaches?
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It is diagnosed by its close relation to a disorder that is known to cause headache.
The headache improves or disappear after successful treatment or spontaneous resolution of the causative illness.
1.Sinus headaches:
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are due to acute sinus inflammation attacks.
Pain is over the frontal forehead and the upper cheeks.
It may be associated with fever and heavy mucus production.
Treatment is by
1.antibiotics for the sinus infection,
2.antihistamines to reduce mucus production
3.painkillers
4.rest.
2.Referred headaches:
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these are caused by by referred pain from disorders of structures around the head. Common ones are
1. earaches,
2. toothache causing pain over an entire part of the face and
3. temporomandibular joint dysfunction from mechanical pain from the jaw joint.
4. temporal arteritis, a rare inflammatory blood vessel condition causing persistent headache at the temporal artery. There is possible complication of blindness secondary to anterior ischemic optic neuropathy. The headache usually resolves or improves with 3 days of high dose steroid treatment.
3.Meningitis / Encephalitis headaches:
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caused by infection of the brain tissue (encephalitis) or the membranes surrounding the brain (meningitis).
Headache is the most common symptom. The pain is diffuse and progressive with fever, a painful stiff neck and other symptoms such as drowsiness, seizures and neurological problems including weakness and numbness.
This type of headache needs immediate hospital treatment.
4.Cerebrovascular Accidents (haemorrhagic stroke):
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a stroke happens when a blood vessel in the brain is blocked or bursts.
Bleeding in the brain causes a sudden severe headache.
There is also associated loss of consciousness and other neurological signs such as weakness, numbness and seizures.
This type of headache needs immediate hospital treatment.
5.Brain Tumour:
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is rare and causes a gradual headache lasting for weeks.
It is localised and associated with nausea, vomiting, loss of appetite and loss of weight.
It is worse in the morning and aggravated by coughing or leaning forward.
By the time neurological symptoms appear such as seizures, numbness, weakness or blindness, the brain tumour has already grown to an advanced stage.
Treatment includes surgery, chemotherapy or radiotherapy.
6. Other causes of secondary headaches are:
a.post traumatic headache following a head injury
b.whiplash injury
c.cerebral venous thrombosis
d. idiopathic intracranial hypertension
e. hydrocephalus
f. sleep apnea
g.cardiac cephalgia
h.acute glaucoma
Simple Treatment of Headache
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Consume a painkiller.
Lie down in a dark, quiet room.
Use muscle relaxation techniques or a gentle massage.
For tension headaches, try a warm bath.
For migraines, put an ice bag or cold towel on your temple.
If the headache do not improve, go for a complete investigation of the headache.
What are the investigations done in Headache?
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You should be investigated for your headache if the headache has:
1. associated fever and and change in mental state.
2. numbness of part of the body or with paralysis.
3. associated fits.
4. sudden onset of severe headache
5. lasted for more than a day even after taking painkillers.
6. increased headache frequency.
7. appeared different from your usual type
8. been precipitated by coughing,sneezing,bending
9. associated with stiff neck and vomiting
10.appeared for the first time in middle age
Common tests:
Blood tests - for infections,raised ESR, bleeding disease
MRI of brain- to exclude brain tumours, bleeding in the brain
Lumbar puncture - used only if there is suspected infection of brain or meninges
