HEADACHE, MIGRAINE AND FACIAL PAIN

Headache is common and the history and examination is the key to diagnosis. Neuroimaging is not indicated in patients who have a clear history of migraine and have no ‘red flag' symptoms or signs (Table 17.2).

Tension headache

Most chronic daily and recurrent headaches are tension headaches. They are thought to be generated by neurovascular irritation and referred to scalp muscles and soft tissues. There is a feeling of pressure or tightness all around the head and there are no associated features of classic migraine (aura, nausea, photophobia). Treatment consists of explanation and reassurance, analgesic withdrawal (to avoid analgesic overuse headache) and tricyclic antidepressants in some cases.

Migraine

Migraine is recurrent headache associated with visual and gastrointestinal disturbance. It is a common condition, occurs more frequently in women and onset is usually before 40 years of age. The diagnosis is clinical.

Pathogenesis

Genetic and environmental factors play a role. Changes in brainstem blood flow lead to an unstable trigeminal nerve nucleus and nuclei in the basal thalamus. This results in release of vasoactive neuropeptides including calcitonin-gene-related peptide (CGRP) and substance P; this then results in the process of neurogenic inflammation of which the two components are vasodilatation and plasma protein extravasation. Cortical spreading depres-sion is a self propogating wave of neuronal and glial depolarization that spreads across the cerebral cortex. It is proposed to cause the aura of migraine and lead to release of inflammatory mediators which impact on the trigeminal nerve nucleus. Precipitating factors include chocolate, cheese, too much or too little sleep, noise and irritating lights, and attacks premenstrually.

Clinical features

Migraine is classified into three types:

■ Migraine with aura (classic migraine)

■ Migraine without aura (common migraine)

■ Migraine variants (unilateral motor or sensory symptoms resembling a stroke).

The headache is characteristically unilateral, throbbing and builds up over minutes to hours. It may be associated with nausea, vomiting and photo-phobia. It may last for some days and is made worse by physical exertion. The patient is irritable and prefers the dark. Premonitory symptoms of fatigue, nausea, changes in mood and appetite may occur in the hours or days before the headache. Auras are related to depression of visual cortical function or retinal function and persist for minutes to hours before the headache. There may be scotomata, unilateral blindness, hemianopic field loss, flashes and fortification spectra. Other aura include aphasia, tingling, numbness and weakness of one side of the body. The most common way in which a migraine attack resolves is through sleep.

Differential diagnosis

A sudden migraine headache may resemble meningitis or subarachnoid haemorrhage. The hemiplegic, visual and hemisensory symptoms must be distinguished from thromboembolic TIAs. In TIAs the maximum deficit is present immediately and headache is unusual (p. 744).

Management

General measures Avoidance of dietary precipitating factors is rarely helpful. Women taking the oral contraceptive pill may be helped by stopping the drug or changing the brand. Hormonal contraceptives are contraindicated in migraine with focal aura.

Treatment of the acute attack

■ Mildattacks. Simple analgesia such as paracetamol (p. 317) or NSAIDs given at the start of the headache and combined with an antiemetic such as metoclopramide (p. 136).

■ Moderate/severe attacks. Triptans, (e.g. sumatriptan, almotriptan, eletriptan, or rizatriptan) are serotonin (5-HT) 1B/1D agonists. They inhibit the release of vasoactive peptides, promote vasoconstriction and block pain pathways in the brainstem. They vary in their onset of action, recur-rence rate and route of administration, e.g. tablets, subcutaneous injec-tion, nasal spray. They are contraindicated when there is vascular disease and in migraine variants. Frequent use of medication for acute attacks may lead to analgesia overuse headache.

Prophylaxis is indicated in patients with frequent attacks (>2 per month) or whom respond poorly to treatment for acute attacks. Options are:

■ Pizotifen (5-HT antagonist), initially 500 μg at night increased gradually to 1.5 mg at night or in 3 divided doses, maximum daily dose 4.5 g. Side-effects are weight gain and drowsiness (hence low starting dose at night)

■ β-Blockers, e.g. propranolol 10 mg three times daily increased to 4080 mg three times daily

■ Amitriptyline 10 mg (or more) at night.

Sodium valproate, topiramate, verapamil, naproxen and methysergide are also used.

Facial pain

The face is richly supplied with pain-sensitive structures - the teeth, gums, sinuses, temporomandibular joints, jaws and eyes - disease of which causes facial pain. Trigeminal (fifth) nerve lesions (p. 732) and trigeminal neuralgia (p. 733) also present with facial pain.

Trigeminal autonomic cephalgias

These headaches are characterized by unilateral trigeminal distribution of pain in association with ipsilateral cranial autonomic features. The group comprises cluster headache, paroxysmal hemicrania, hemicrania continua, and short lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT syndrome). They are rare other than cluster headache.

Cluster headaches (migrainous neuralgia)

These are rapid onset, severe, short lived (1-2 hours), unilateral headaches with a clustering of painful attacks over weeks or months followed by periods of remission. Men are affected more commonly than women with a peak age of onset of 20-50 years. The pain often begins around the eye or temple. Autonomic features are lacrimation and redness of the eye, rhinorrhoea and Horner's syndrome. Treatment of an acute attack is with subcutaneous or nasal triptans or inhalation of 100% oxygen. Verapamil, topiramate, lithium carbonate and/or a short course of steroids helps to bring about an end to a bout of clusters.

Giant cell arteritis (cranial or temporal arteritis)

This is a granulomatous arteritis of unknown aetiology occurring chiefly in those over the age of 60 and affecting in particular the extradural arteries. Giant cell arteritis is closely related to polymyalgia rheumatica (p. 307) and this can occur in the same patient.

Clinical features

There is headache, scalp tenderness (e.g. on combing the hair) and occasionally pain in the jaw and mouth which is characteristically worse on eating (jaw claudication). The superíicial temporal artery may become tender, firm and pulseless. Blindness, caused by inflammation and occlusion of the ciliary and/or central retinal artery, occurs in 25% of untreated cases. Systemic features include weight loss, malaise and a low-grade fever.

Investigations

■ ESR is always elevated >50 mm/h

■ Full blood count may show a normochromic, normocytic anaemia

■ Histology. A temporal artery biopsy, which can be performed under local anaesthetic, usually confirms the diagnosis. However, the granulomatous changes may be patchy and therefore missed.

Management

High doses of steroids (oral prednisolone, initially 60-100 mg daily) should be started immediately in a patient with typical features, and a temporal artery biopsy obtained as soon as possible (the histological changes remain for up to a week after starting treatment). The steroid dose is gradually reduced, guided by symptoms and the ESR. Long-term steroids may be needed because the risk of visual loss persists.

Ebook Essentials of Kumar and Clark's Clinical Medicine, 5e

1. Ethics and communication

Ethics and communication

2. Infectious diseases

Infectious diseases

3. Gastroenterology and nutrition

Gastroenterology and nutrition

4. Liver, biliary tract and pancreatic disease

Liver, biliary tract and pancreatic disease
LIVER BIOCHEMISTRY AND LIVER FUNCTION TESTS
SYMPTOMS AND SIGNS OF LIVER DISEASE
JAUNDICE
HEPATITIS
NON - ALCOHOLIC FATTY LIVER DISEASE (NAFLD)
CIRRHOSIS
COMPLICATIONS AND EFFECTS OF CIRRHOSIS
LIVER TRANSPLANTATION
TYPES OF CHRONIC LIVER DISEASE AND CIRRHOSIS
PRIMARY SCLEROSING CHOLANGITIS
BUDD - CHIARI SYNDROME
LIVER ABSCESS
LIVER DISEASE IN PREGNANCY
LIVER TUMOURS
GALLSTONES
THE PANCREAS
CARCINOMA OF THE PANCREAS
NEUROENDOCRINE TUMOURS OF THE PANCREAS

5. Haematological disease

Haematological disease
ANAEMIA
Assessment and treatment of suspected neutropenic sepsis
HAEMOLYTIC ANAEMIA
INHERITED HAEMOLYTIC ANAEMIAS
ACQUIRED HAEMOLYTIC ANAEMIA
MYELOPROLIFERATIVE DISORDERS
THE SPLEEN
BLOOD TRANSFUSION
THE WHITE CELL
HAEMOSTASIS AND THROMBOSIS
THROMBOSIS
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Malignant disease
MYELOABLATIVE THERAPY AND HAEMOPOIETIC STEM CELL TRANSPLANTATION
THE LYMPHOMAS
THE PARAPROTEINAEMIAS
PALLIATIVE MEDICINE AND SYMPTOM CONTROL

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Rheumatology
COMMON INVESTIGATIONS IN MUSCULOSKELETAL DISEASE
COMMON REGIONAL MUSCULOSKELETAL PROBLEMS
BACK PAIN
OSTEOARTHRITIS
INFLAMMATORY ARTHRITIS
THE SERONEGATIVE SPONDYLOARTHROPATHIES
Clinical features, Investigations
INFECTION OF JOINTS AND BONES
AUTOIMMUNE RHEUMATIC DISEASES
SYSTEMIC INFLAMMATORY VASCULITIS
DISEASES OF BONE
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8. Water, electrolytes and acid–base balance

WATER AND ELECTROLYTE REQUIREMENTS
BODY FLUID COMPARTMENTS
REGULATION OF BODY FLUID HOMEOSTASIS
PLASMA OSMOLALITY AND DISORDERS OF SODIUM REGULATION
DISORDERS OF POTASSIUM REGULATION
DISORDERS OF MAGNESIUM REGULATION
DISORDERS OF ACID - BASE BALANCE
THERAPEUTICS

9. Renal disease

Renal disease
INVESTIGATION OF RENAL DISEASE
GLOMERULAR DISEASES
NEPHROTIC SYNDROME
URINARY TRACT INFECTION
TUBULOINTERSTITIAL NEPHRITIS
HYPERTENSION AND THE KIDNEY
RENAL CALCULI AND NEPHROCALCINOSIS
URINARY TRACT OBSTRUCTION
ACUTE RENAL FAILURE/ACUTE KIDNEY INJURY
CHRONIC KIDNEY DISEASE
RENAL REPLACEMENT THERAPY
CYSTIC RENAL DISEASE
TUMOURS OF THE KIDNEY AND GENITOURINARY TRACT
DISEASES OF THE PROSTATE GLAND
TESTICULAR TUMOUR
URINARY INCONTINENCE

10. Cardiovascular disease

COMMON PRESENTING SYMPTOMS OF HEART DISEASE
INVESTIGATIONS IN CARDIAC DISEASE
CARDIAC ARRHYTHMIAS
HEART FAILURE
ISCHAEMIC HEART DISEASE
RHEUMATIC FEVER
VALVULAR HEART DISEASE
PULMONARY HEART DISEASE
MYOCARDIAL DISEASE
CARDIOMYOPATHY
PERICARDIAL DISEASE
SYSTEMIC HYPERTENSION
ARTERIAL AND VENOUS DISEASE
ELECTRICAL CARDIOVERSION
DRUGS FOR ARRHYTHMIAS
DRUGS FOR HEART FAILURE
DRUGS AFFECTING THE RENIN - ANGIOTENSIN SYSTEM
NITRATES, CALCIUM - CHANNEL BLOCKERS AND POTASSIUM - CHANNEL ACTIVATORS

11. Respiratory disease


Respiratory disease
TUBERCULOSISnd
DIFFUSE DISEASES OF THE LUNG PARENCHYMA
OCCUPATIONAL LUNG DISEASE
CARCINOMA OF THE LUNG
DISEASES OF THE CHEST WALL AND PLEURA
DISORDERS OF THE DIAPHRAGM

12. Intensive care medicine

Intensive care medicine

13. Drug therapy, poisoning, and alcohol misuse

Drug therapy, poisoning, and alcohol misuse

14. Endocrine disease

Endocrine disease
PITUITARY HYPERSECRETION SYNDROMES
THE THYROID AXIS
MALE REPRODUCTION AND SEX
FEMALE REPRODUCTION AND SEX
THE GLUCOCORTICOID AXIS
THE THIRST AXIS
DISORDERS OF CALCIUM METABOLISM
DISORDERS OF PHOSPHATE CONCENTRATION
ENDOCRINOLOGY OF BLOOD PRESSURE CONTROL
DISORDERS OF TEMPERATURE REGULATION
THERAPEUTICS

15. Diabetes mellitus and other disorders of metabolism

DIABETES MELLITUS
DIABETIC METABOLIC EMERGENCIES
COMPLICATIONS OF DIABETES
SPECIAL SITUATIONS
HYPOGLYCAEMIA IN THE NON - DIABETIC
DISORDERS OF LIPID METABOLISM
THE PORPHYRIAS

16. The special senses

THE EAR
THE NOSE AND NASAL CAVITY
THE THROAT
THE EYE

17. Neurology

COMMON NEUROLOGICAL SYMPTOMS
COORDINATION OF MOVEMENT
THE CRANIAL NERVES
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STROKE AND CEREBROVASCULAR DISEASE
EPILEPSY AND LOSS OF CONSCIOUSNESS
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HEADACHE, MIGRAINE AND FACIAL PAIN
SPINAL CORD DISEASE
DEGENERATIVE NEURONAL DISEASES
DISEASES OF THE PERIPHERAL NERVES
MUSCLE DISEASES
MYOTONIAS
DELIRIUM
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18. Dermatology

Dermatology

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