SOURCE OF HEADACHE:

skin, fat, muscle, blood vessels, periosteum. great venous sinus & their tributaries, the dura at the base of the skull, dural arteries, falx cerebri, and large arteries of base of the brain.
 The actual brain parenchyma, most of the

dura, arachnoid and pia mater have no pain receptors.

Pathophysiology:
 Trigeminovascular

neuronal

transmission

abnormalities Vascular structures Neurogenic inflammation Moskowitz suggest that trigeminovascular system activation induces vasodilatation and neurogenic plasma development of neurogenic inflammation.

MIGRAINE
 12% of population  70% have positive family history for similar

headache  Migraine is asso. with mood and anxiety, but is more commonly associated with depression.  3-4x more common in women  usually begins in adolescence or young adulthood

A. Migraine without Aura

 majority of people with migraine do NOT have aura  previously called Common Migraine  lasts 4 to 72 hrs. 
1. Unilateral position 2. Pulsating quality 3. Moderate or severe intensity 4. Aggravated by climbing stairs or similar

activity

1. Nausea or vomiting or both 2. Photophobia and phonophobia

 At least 5 attacks fulfilling above criteria

before diagnosis can be made.

B. Migraine with Aura

 15% of people with migraine will experience

an aura prior to some of their attacks.

 previously called Classic Migraine

1. One or more fully reversible aura symptoms

indicating brain dysfunction. 2. At least one aura symptom develop gradually over more than 4 minutes or 2 or more symptoms occur in succession. 3. No single aura symptom last more than 60 minutes. 4. Headache follows aura with a symptom-free interval of less than 60 minutes.

 At least 2 attacks before diagnosis is made.  Most common aura is visual

scotoma in the form of an arc of scintillating lights in a herring bone-like pattern is almost pathognomonic, homonymous visual disturbances, unilateral paresthesias or numbness, unilateral weakness, and aphasia or unclassified speech difficulties.

Factors common to Migraine with or without aura:

 can be provoked or intensified by changes in the

body s internal milieu and by environmental factors  menstruation  changes in body rhythm such as to little sleep, too much sleep or fasting  hot, humid weather  alcoholic beverages (tyramine content and vasodilating effect)  Phenylethylamine in chocolate  MSG  caffeine  contraceptives and nitrates

C. Ophthalmoplegic Migraine
 usually seen in young adults  relatively rare  3rd, 4th and 6th cranial nerves are usually

involved.  dilated outwardly deviated eyes with ptosis  pain moderate in intensity and ipsilateral with ophthalmoplegia

D. Hemiplegic Migraine
 uncommon  unilateral

motor and sensory symptoms ranging from mild hemiparesis to full hemiplegia  symptoms may persist longer than headache and should be diagnosed by exclusion.

E. Cluster Headache
 seen in males, predominantly middle adulthood  unilateral intense ocular or retroocular pain lasting

less than 2 hours but occurring several times a day for periods of weeks to months.  facial flushing, forehead sweating, lacrimation, rhinorrhea and conjunctival injection on the side of the pain.  pain is incapacitating.  associated ipsilateral Horner s syndrome.  may follow ingestion of alcohol.

NON-MIGRAINOUS VASCULAR HEADACHE

 non-recurrent, throbbing headache  not associated with specific functional loss  presenting symptoms may be similar to those

of migraine  bicranial

TOXIC METABOLIC HEADACHE

 Caused by vasodilatation of pain sensitive

arteries often combined with lowering of pain threshold by the toxic metabolic substance itself.  Fever greater than 38.8oC most common cause. Tyramine containing foods and MSG.  Oral contraceptives, nitrates.  Insulin dependent diabetics.  Definitive treatment is removal of the cause with analgesic supplementation.

HYPERTENSIVE HEADACHE
 Throbbing occipital headache  Diastolic BP exceeds 130 mmHg

MUSCULAR CONTRACTION AND TRACTION HEADACHES

TENSION HEADACHE
 Sustained contraction of deep neck muscles

and muscles of mastication.  Constant, non-throbbing, vise-like bilateral pain with focal areas of pain in the bioccipital regions.  Scalp tenderness / muscle spasm.

TRACTION HEADACHE

 Secondary to direct pressure, traction or

displacement of pain-sensitive structures, esp. blood vessels.

MASS LESIONS

SUBDURAL HEMATOMA
 Depression

of mental status out of proportion to focal findings with a headache of variable quality.  May be traumatic or atraumatic.  May be acute or chronic.

EPIDURAL HEMATOMA
 May progress to truncal herniation.  Usually there is a history of trauma.  Brief episode of unconsciousness followed

by consciousness with headache.  Usually with fracture line through the middle meningeal groove.

POST-CONCUSSIVE HEADACHE
 May follow trauma within hours to days.  Associated with vertigo, nausea, and

vomiting.  Difficulty with concentration and mood alterations.  Self-limiting.

SUBARACHNOID HEMORRHAGE
 Bleeding from Intracranial Aneurysm.  Arteriovenous Malformation  Sudden and intense.  Worst headache of patient s life.

POST-LUM AR PUNCTURE
 Caused by leakage of fluid through dural

puncture site.  There is reduction of CSF volume below the cisterna magna with downward movement resulting in pain.  Bicranial, pulsatile, frontal headache which is exacerbated by upright position.

BRAIN ABSCESS
 Findings similar to those with space-

occupying lesions.
 With history of fever.