14 HEADACHE

Neil H. Raskin
Few of us are spared the experience of head pain. As many as 90% of
individuals have at least one headache per year. Severe, disabling
headache is reported to occur at least annually by 40% of individuals
worldwide. Auseful classification of the many causes of headache is
shown in Table 14-1. Headache is usually a benign symptom, but
occasionally it is the manifestation of a serious illness such as brain
tumor, subarachnoid hemorrhage, meningitis, or giant cell arteritis. In
emergency settings, approximately 5% of patients with headache are
found to have a serious underlying neurologic disorder. Therefore, it
is imperative that the serious causes of headache be diagnosed rapidly
and accurately.
PAIN-SENSITIVE STRUCTURES OF THE HEAD
Pain usually occurs when peripheral nociceptors are stimulated in response
to tissue injury, visceral distension, or other factors (Chap. 11).
In such situations, pain perception is a normal physiologic response
mediated by a healthy nervous system. Pain can also result when painsensitive
pathways of the peripheral or central nervous system are
damaged or activated inappropriately. Headache may originate from
either or both mechanisms. Relatively few cranial structures are painsensitive:
the scalp, middle meningeal artery, dural sinuses, falx cerebri,
and the proximal segments of the large pial arteries. The ventricular
ependyma, choroid plexus, pial veins, and much of the brain
parenchyma are pain-insensitive. Electrical stimulation of the midbrain
in the region of the dorsal raphe has resulted in migraine-like headaches.
Thus, whereas most of the brain is insensitive to electrode probing,
a site in the midbrain represents a possible source of headache
generation. Sensory stimuli from the head are conveyed to the central
nervous system via the trigeminal nerves for structures above the tentorium
in the anterior and middle fossae of the skull, and via the first
three cervical nerves for those in the posterior fossa and the inferior
surface of the tentorium.
Headache can occur as the result of (1) distention, traction, or dilation
of intracranial or extracranial arteries; (2) traction or displacement
of large intracranial veins or their dural envelope; (3) compression,
traction, or inflammation of cranial and spinal nerves; (4) spasm,
inflammation, or trauma to cranial and cervical muscles; (5) meningeal
irritation and raised intracranial pressure; or (6) other possible mechanisms
such as activation of brainstem structures.
GENERAL CLINICAL CONSIDERATIONS
The quality, location, duration, and time course of the headache and
the conditions that produce, exacerbate, or relieve it should be carefully
reviewed. Ascertaining the quality of cephalic pain is occasionally
helpful for diagnosis. Most tension-type headaches are described
as tight “bandlike” pain or as dull, deeply located, and aching pain.
Jabbing, brief, sharp cephalic pain, often occurring multifocally (ice
pick–like pain), is usually benign. Athrobbing quality and tight muscles
about the head, neck, and shoulder girdle are common nonspecific
accompaniments of migraine headaches.
Pain intensity rarely has diagnostic value, although from the patient’s
perspective, it is the single aspect of pain that is most important.