4 HEADACHE AND FACIAL PAIN
Harrison’s Manual of Medicine
HEADACHE AND FACIAL PAIN
Causes of headache are summarized in Table 4-1. First step—distinguish serious from benign etiologies. Symptoms that raise the suspicion for a serious cause are listed in Table 4-2; serious causes are summarized in Table 4-3. Intensity of head pain rarely has diagnostic value. Headache location can suggest involvement of local structures (temporal pain in giant cell arteritis, facial pain in sinusitis). Ruptured aneurysm (instant onset), cluster headache (peak over 3–5 min), and migraine (onset over minutes to hours) differ in time to peak intensity. Therapeutic trials of medication do not provide diagnostic information due to high frequency of placebo responders (~30%). Provocation by environmental factors suggests a benign cause.
Table 4-1 The Classification of Headache
Table 4-2 Headache Symptoms That Suggest a Serious Underlying Disorder
Table 4-3 Serious Causes of Headache
Frequency of symptoms associated with migraine is listed in Table 4-4.
Table 4-4 Symptoms Accompanying Severe Migraine Attacks in a Group of 500 Patients
CLASSIC MIGRAINE Onset usually in childhood, adolescence, or early adulthood; however, initial attack may occur at any age. Family history often positive. More frequent in women. Classic triad: premonitory visual (scotoma or scintillations) sensory or motor symptoms, unilateral throbbing headache, nausea and vomiting. Photo- and phonophobia common. Focal neurologic disturbances without headache or vomiting (migraine equivalents) may also occur. An attack lasting 2–6 h is typical, as is relief after sleep. Attacks may be triggered by wine, cheese, chocolate, contraceptives, stress, exercise, or travel.
COMMON MIGRAINE Unilateral or bilateral headache with nausea, but no focal neurologic symptoms. Moderate-to-severe head pain, pulsating quality, unilateral, worse with activity; associated with photophobia, phonophobia, multiple attacks. More common in women. Onset more gradual than in classic migraine; duration 4–72 h.
Three approaches to migraine treatment: nonpharmacologic (Table 4-5), drug treatment of acute attacks (Table 4-6), and prophylaxis (Table 4-7). Drug treatment necessary for most migraine patients, but avoidance or management of environmental triggers is sufficient for some. General principles of pharmacologic treatment: (1) response rates vary from 60–90%; (2) initial drug choice is empirical—influenced by patient age, coexisting illnesses, and side effect profile; (3) efficacy of prophylactic treatment may take several months to assess with each drug; (4) when an acute attack requires additional medication 60 min after the first dose, then the initial drug dose should be increased for subsequent attacks. Mild-to-moderate acute migraine attacks often respond to over-the-counter (OTC) NSAIDs when taken early in the attack. Triptans are widely used also, but recurrence of head pain after the first dose (40– 78%) is a major limitation. There is less frequent headache recurrence when using ergots, but more frequent side effects. For prophylaxis, amitriptyline is a good first choice for young people with difficulty falling asleep; verapamil is often a first choice for prophylaxis in the elderly.
Table 4-5 Nonpharmacologic Approaches to Migraine
Table 4-6 Drugs Effective in Acute Treatment of Migraine
Table 4-7 Drugs Effective in the Prophylactic Treatment of Migraine
CLUSTER HEADACHE Characterized by episodes of recurrent, nocturnal, unilateral, retroorbital searing pain. Typically, a young male (90%) awakens 2–4 h after sleep onset with severe pain, unilateral lacrimation, and nasal and conjunctival congestion. Visual complaints, nausea, or vomiting are rare. Pain lasts 30–120 min but tends to recur at the same time of night or several times each 24 h over 4–8 weeks (a cluster). Diurnal periodicity (recurrent pain during the same hour each day of the cluster) occurs in 85%. A pain-free period of months or years may be followed by another cluster of headaches. Alcohol provokes attacks in 70%. Prophylaxis with lithium (600–900 mg qd) or prednisone (60 mg for 7 d followed by a rapid taper). Ergotamine, 1 mg suppository 1–2 h before expected attack, may prevent daily episode. High-flow oxygen (9 L/min) or sumatriptan ( 6 mg SC) is useful for the acute attack.
TENSION HEADACHE Common in all age groups. Pain is holocephalic, described as pressure or a tight band. May persist for hours or days. Often related to stress; responds to relaxation and simple OTC analgesics (i.e., aspirin, acetaminophen, ibuprofen). Amitriptyline may be helpful for prophylaxis (Table 4-8). Distinction from common migraine may be difficult.
Table 4-8 Drugs Effective in the Treatment of Tension-Type Headache
Post-Concussion Headache Common following motor vehicle collisions, other head trauma; severe injury or loss of consciousness often not present. Symptoms of headache, dizziness, vertigo, impaired memory, poor concentration, irritability; typically remits after several weeks to months. Neurologic examination and neuroimaging studies normal. Not a functional disorder; cause unknown.
Lumbar Puncture Headache Typical onset 24–48 h after LP; follows 10–30% of LPs. Positional: onset when pt sits or stands, relief by lying flat. Most cases remit spontaneously in £1 week. Intravenous caffeine (500 mg IV, repeat in 1 h if dose ineffective) successful in 85%; epidural blood patch effective immediately in refractory cases.
Cough Headache Transient severe head pain with coughing, bending, lifting, sneezing, or stooping; lasts from seconds to several minutes; men > women. Usually benign, but posterior fossa mass lesion in ~25%. Consider brain MRI.
Most common cause of facial pain is dental; triggered by hot, cold, or sweet foods. Exposure to cold repeatedly induces dental pain.
Trigeminal Neuralgia Paroxysmal, fleeting, electric shock-like episodes of pain; maxillary distribution of trigeminal nerve more often affected than mandibular. Most cases idiopathic; patients under age 50 at risk for structural cause (multiple sclerosis, vascular anomaly, tumor). Treatment: carbamazepine (400–1600 mg/d) usually effective; phenytoin, baclofen, and valproic acid are other options.
Postherpetic Neuralgia Pain following skin rash of herpes zoster; may be associated with sensory loss. Pain usually resolves over weeks.
Occipital Neuralgia Entrapment of greater occipital nerve at exit from skull; unilateral, lancinating occipital pain. Percussion over exit point of greater occipital nerve may elicit symptoms. Treatment: block-injection of steroid and local anesthetic.
For a more detailed discussion, see Raskin NH, Peroutka SJ: Headache, Including Migraine and Cluster Headache, Chap. 15, p. 70, in HPIM- 15.