DEFINITION

Headache is the most common type of pain in head experience by all humans caused by the excitation of pain sensitive structures of the head namely venous sinuses, Dura, cranial blood vessels and the branches of Trigeminal Nerve.

TYPES OF HEADACHE

• Tension Type Headache: It is the most common type of headache characterized by its bilateral location and with pressing or tightening Quality and with mild or moderate Intensity.
• Migraine Headache: It is a recurring type of headache characterized by Unilateral or Bilateral throbbing pain usually aggravated by a precipitating factor or a triggering event
• Cluster Headache: It is a rare form of radiating type of unilateral headache that involves repeated episodes of Headaches that occurs over a weeks to month at a time followed by remissions.

ETIOLOGY OF HEADACHE

• Tension type Headache: 
  • Intracranial/ subarachnoid hemorrhage/masses
  • Diseases of Eyes, Nose & Teeth
  • Systemic Illness like Bacteremia, Poisoning, mountain sickness & polycythemia Vera
  • Physical Status like life adjustments, family situation & Environment
• Migraine Headache:
  • Hormonal Fluctuation
  • Head Trauma
  • Physical Exertion
  • Fatigue
  • Stress
  • Pharmacological Agents like Monosodium Glutamate, Aspartate, Red wine
  • Foods Like Chocolates, Cheese, Tomatoes, Oranges & Onions
• Cluster Headache:
  • Dysfunction of Intra-cranial Blood vessels
  • Pain modulation systems of the sympathetic Nervous System
  • Genetic Component/ Family History of Headaches
  • Smoking & Alcohol Ingestion

PATHOPHYSIOLOGY OF TENSION TYPE HEADACHE

Any factors/ Conditions that triggers the Nerve Impulses

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Sustained Contraction of the muscles of the scalp and neck

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Compression of the nearby Nerves

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Painful sensitization of Nerves (Tension type Headache)

THEORIES OF MIGRAINE HEADACHE

• Vascular Theory

Any condition that causes changes in the cerebral blood vessels

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Sudden vascular changes in the cerebral blood vessels

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Vasoconstriction followed by Vasodilation

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Alteration/ Changes in the flow of Blood

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Restriction of blood supply to the surrounding Nerves & tissues

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Extravasation of fluid to the nearby tissue Spaces

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Compression of the muscles & Neuronal dysfunction

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Characterized by throbbing Headache

• Muscular Theory

Any factors like excessive stress or physical Exertion

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Tension in the muscles of the scalp & Head

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Contraction of the muscles

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Compression of the surrounding structures including nerves & blood vessels

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Painful Sensation in the head

• Bio-chemical Theory

Changes In the Serotonin Pathway

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Serotonin that are stored in the platelets are released in to the plasma

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Inactivation of the Serotonin

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Low Serotonin levels dilate Blood vessels

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Constriction of the Nerves

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causes Migraine like Headache

PATHWAY OF CLUSTER HEADACHE

CLINICAL MANIFESTATIONS OF TENSION TYPE HEADACHE

• Photophobia (Sensitivity to Light)
• Phonophobia (Sensitivity to sound)
• Head & Neck Tenderness

CLINICAL MANIFESTATIONS OF MIGRAINE HEADACHE:

• Aura (Unilateral Throbbing pain lasting for 10-30 minutes)
• Sensory Dysfunction like visual Field Defects, tingling or burning sensation & Paresthesias
• Motor Dysfunction like weakness, paralysis
• Dizziness
• Confusion
• Loss of consciousness
• Generalized Edema
• Irritability
• Pallor
• Nausea & Vomiting
• Sweating
• Psychic Disturbances
• GI Upset
• Changes in Fluid Balance
• Hibernate (seek shelter from Noise, Light, Odors, People & Problem

CLINICAL MANIFESTATIONS OF CLUSTER HEADACHE:

• Intense pain lasting for 1 hour
• Pain locating around the eye radiating to the temple, forehead, cheeks, Nose & Gums
• Swelling around the eye
• Lacrimation (tearing)
• Facial Flushing or pallor
• Rhinorrhea
• Pupillary Constriction
• Agitation & Restlessness

DIAGNOSTIC FINDINGS OF HEADACHE:

• History to identify the precipitating factors or triggering events of headache  like stress, exertion, Infection, injury etc.
• Physical Examination reveals the type, Quality, Intensity & severity of headache
• Routine Laboratory Studies Like CBC, Sr. Electrolytes & Urinalysis to monitor electrolyte & Metabolic abnormalities
• Electromyography reveals sustained Contraction of neck, Scalp & Facial Muscles in tension type headache
• CT Scan with or without Contrast to evaluate head trauma & rule out Intracranial Disorders
• MRI  with Angiography to Identify Cerebral Abnormalities

PHARMACOLOGICAL MANAGEMENT OF HADACHE

• Tension type Headache:
  • Non-Opioid Analgesics :- like Aspirin, Ibuprofen, Acetaminophen
  • Analgesics :- like Fiorinal, Fioricet, Midrin
  • Tricyclic Antidepressants:-like Doxepin, Amitriptyline
  • Β-Adrenergic Blockers:-Propranolol
• Migraine Headache:
  • Serotonin Receptor Agonists:- like Almotriptan Eletriptan, Frovatriptan, Naratriptan, Rizatriptan, Sumatriptan & Zolmitriptan
  • α-Adrenergic Blockers:- like Ergotamine Tartrate, Dihydroergotamine
  • Analgesic Combinations:- like Midrin
  • Corticosteroids:- like Dexamethasone
  • Β-Adrenergic Blockers:- like Propranolol
  • Antidepressants:- like Amitriptyline & Imipramine
  • Serotonin antagonist:-like Methysergide
  • Calcium Channel Blockers:- like Verapamil
• Cluster Headache:
  • α-Adrenergic Blockers:- like Ergotamine Tartrate,
  • Serotonin antagonist:- like Methysergide
  • Calcium Channel Blockers:- like Verapamil
  • Lithium
  • Corticosteroids:-like Prednisone

COLLABORATIVE CARE

• Identify the precipitating factors and avoid them.
• Daily exercise, Relaxation & Socialization should be encouraged to decrease the recurrence of headache
• Meditation, Yoga & Self hypnosis can be suggested to patients as an alternate techniques of handling headache
• Symptomatic relief with drugs must be administered
• In case of Migraine Headache a quiet & dim light Environment must be provided
• Massage with Balm and moist hot packs can help to relieve tension type headaches
• For patients whose head ache is triggered by foods counseling should be provided to avoid those foods like chocolates, Oranges, Tomatoes, cheese, Onions, Red wine, alcohol, caffeine & Marinated foods
• Avoid Exposure to smoking & other volatile gases like strong perfumes & gasoline Fumes.
• Patients with cluster headache need Oxygen therapy, especially during air travel high altitudes can trigger headache, So advice these patients to take Ergotamine tartrate  before takeoff  during air travel.

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