Headache

Basics

Description

  • Pain in the cranium, orbits, or upper neck
  • Pain within the skull is projected to the surface:
    • Intracranial:
      • Arteries, veins, dura, meninges
    • Extracranial:
      • Skin, scalp, fascia, muscles
      • Mucosal linings of the sinuses
      • Arteries
      • Temporomandibular joints, teeth
  • Pain is transmitted via the V cranial nerve
  • May be caused by a number of mechanisms:
    • Nerve irritation
    • Traction on pain-sensitive vessels
    • Vasodilatation of pain-sensitive vessels
      • Hypoxia, hypercapnia, fever, histamine injection, nitroglycerin ingestion
  • Complaint in 2–4% of all ED visits:
    • 95% have a benign etiology (lower in patients >50 yr)
    • Life-threatening etiologies are rare and can be difficult to diagnose

Etiology

  • Migraine:
    • Intra/extracranial vasodilatation and constriction of pain-sensitive blood vessels
    • May also involve cortical depression
    • Throbbing headache
  • Tension:
    • Requires ≥10 attacks of a similar nature
    • Unknown etiology (possibly serotonin imbalance, decreased endorphins, spasm)
    • Most common type of recurring headache
    • Triggered by poor posture, stress, anxiety, depression, cervical osteoarthritis
    • Bilateral, nonpulsatile, band-like
    • Mild to moderate intensity
    • 4–13 hr duration
  • Cluster headaches:
    • Triggered by alcohol, certain foods, altered sleep habits, strong emotions
    • May involve vasospasm near cranial nerves
  • Intracranial (traction, pressure):
    • Mass lesions
    • Idiopathic intracranial hypertension
  • Extracranial (compression):
    • Pathology causing pain in a peripheral nerve of the head and neck
  • Inflammation:
    • Temporal arteritis
    • Cerebral vasculitis
  • Thrombosis:
    • Cerebral venous sinus thrombosis (CVST)
  • Impaired vascular autoregulation/endothelial dysfunction:
    • Posterior reversible leukoencephalopathy syndrome (PRES)
    • Reversible cerebral vasoconstriction syndrome (RCVS)

Pediatric Considerations
Serious causes of headache in children are rare but those who come to the ED for this complaint should all have follow-up with a pediatrician


Geriatric Considerations
Older patients with new headache have a higher likelihood of a serious etiology and should have more thorough evaluation with a low threshold for imaging


Pregnancy Considerations
In addition to all other causes of headache, pregnant women (and recently postpartum women) are at increased risk for CVST, eclampsia, PRES, and RCVS

There's more to see -- the rest of this topic is available only to subscribers.