Definition of the headache.
Headache means the feeling of the pain or discomfort localized within the area over the eyebrows and up to the cervical-occipital area.
The most frequent causes of the headache are considered:
The intracranial infections: the meningitis, meningoencephalitis, thrombosis of sinuses of the dura mater, and also postherpetic neuralgia.
The diseases of vessels: the subarachnoid hemorrhages, transient disturbances of the cerebral circulation, strokes, chronic failure of the cerebral circulation, hypertension, atherosclerosis, vasculitis, and collagenosis.
The blood diseases: leukosis, polycythemia, syndrome of the increased blood viscosity.
The injuries: the acute craniocerebral trauma, post-traumatic brain disease.
The high intracranial pressure: the volume processes (the tumor, hematoma, or abscess), brain edema of different genesis.
The low intracranial pressure: after punctures in the hypotension.
The hypercapnia: the respiratory failure, sleeps apnea the sleep.
The endocrine disorders: hypothyroidism, premenstrual syndrome, etc.
The diseases of the eyes, ears, teeth, salivary glands, nasal sinuses, temporal-mandibular joint, cervical spine, bones of the skull, and main arteries of the head.
The intoxications with: alcohol, carbon monoxide, nitroglycerin, antibacterial drugs (Rifampicin, Ethionamide, Cycloserine), Indomethacin, Biphenyl, Carbamazepine, and antidepressants.
The pathogenesis of the headache.
The mechanical, temperature, chemical factors take part in its formation. The most aggressive are the endogenous pain substances biogenic amines (histamine, serotonin), polypeptides (bradykinin), and ions of Na+ K+, and also prostaglandins. The specific mediator of the pain is the substance P.
The substance P take the first place in mediation and modulation of the pain at the segmental and suprasegmental levels.
Pathogenetic Classification of the Headaches .
The following types of headaches:
The tension headache.
Occurs in the tension or compression of muscles of the scalp and masseters. Intensifying of the neuromuscular excitation occurs in the sympathetic-adrenal activation appearing on the background of emotional stress. In development of the tension headache also the significant role is played by the segmental reflex mechanisms.
The tension headache (TH).
Is an independent nosological form. It is the most widespread form of the primary headache, which is manifested by the long bilateral gripped pain of moderate intensity, which often is associated with the tension of the pericranial muscles. There are the incidental (several times a month) and chronic (more than 15 times a month, including daily) pressing headache. The pain occurs at any time of day or night, lasts from several hours to several days.
The diagnostic criteria of TH .
The duration of the headache not less than 30 minutes; specific character of the headache (the feeling of head compression wrap, a bandage — 'neurasthenic helmet’); its low intensity. The pain is diffuse, bilateral, doesn’t increase during the physical load. The throbbing pain isn’t typical. The pressing headache is accompanied by nonsystemic dizziness, general weakness, and increased sensitivity to any stimuli. The nausea, vomiting, and vegetative disorders are not typical. The pain decreases or disappears after rest and psychological relaxation.
The neuralgic pain (NP).
It is the prosopalgia (the facial pain). The paroxysmal attacks of the pain occur; they last several seconds or minutes and appear one after another with small intervals. The pain is resembled to a blow of electric current (like a lightning). The trigger: zones or pain spots, which irritation provokes the paroxysm, are characteristic for the neuralgic pain. At the moment of the paroxysm the patient fades; he (she) is afraid once again to open the mouth, blink eyes, avoiding movements with the head.
The combined headache.
Occurs in the combined influence of two or more mechanisms. This case is most often observed.
The psychogenic mechanism of the headache.
Psychalgia becomes perceptible dysfunction of the central antinociceptive system owing to disturbance of the exchange c monoamines and endogenic opiates that leads to disturbances of the antinociceptive system.
The clinical classification of the headache .
The tension headache.
The cluster headache and chronic paroxysmal hemicranias.
The primary headache of other genesis.
The pain because of the injury of the head or neck.
The headache because of a lesion of vessels of the brain and neck.
The headache connected with the non-vascular intracranial disorders.
The headache connected with the use of certain substances or their cancelation.
The headache due to non-cerebral infections.
The headache because of disturbance of the homeostasis.
The head or facial pain due to the pathology of the skull, neck, eyes, ears, nose, nasal sinuses, teeth, mouth, or other facial or cranial structures.
The headache because of the mental diseases.
The cranial neuralgias and central causes of the facial pain.
Other headaches, cranial neuralgias, the central and primary facial pain.
First three forms are primary headaches.
The primary headache .
Is an independent nosological form, which includes the migraine, cluster headache, the chronic paroxysmal hemi-cephalgia, and the tension headache.
In the secondary headache .
Headache is the syndrome and need to prescribe the treatment of the main disease, which caused the pain.
The treatment of the headache.
The elimination of causes of the headaches.
The vasomotor cephalgias - prescribe alpha- or beta-blockers (Pyroxan, Regelin, Sermion, Inderal, Atenolol, Propranolol), antagonists of calcium (Stugeron, Sibelium, Nimotop, Cinnarizine), and belloid preparation.
In the venous cephalgias venotonics (Detralex, Phlebodia. Lysine escinat, Troxevasin, Anavenol) are used; in the intracranial hypertension they prescribe osmotic diuretics (Mannitol, Glycerol), saluretics (Furosemide, Hydrochlorothiazide), potassium-sparing diuretics (Verospiron, Diakarb, etc.). The dehydrational agents often are combined with venotonics.
The treatment of the hypotension.
Provides staying in bed. increased consumption of the salt, and drinking of much fluid.
The pressing headache needs the reflex methods of the treatment (massage of the neck area, physiotherapeutic methods of influence), carrying out the psychotherapy, prescription of antidepressants, muscle relaxants (Mydocalm, Sirdalud, Baclofen, Myolastan).
In the neuralgic pain preparations of Carbamazepine (Finlepsin, Carbamazepine), Gabapentin, Lamotrigine are prescribed. In the psychogenic headache they use the psychotherapeutic methods, tranquilizers, and antidepressants.
Is the paroxysmal headache of the throbbing character, which occurs most often in one half of the head; rarer it may be bilateral, on intensity varies from moderate to sharp.
The migraine attacks often are followed by the anorexia, sometimes nausea and vomiting. The headache duration on average fluctuates from 4 to 72 hours.
From 12—15 % of population suffer from the migraine. The genetic predisposition to this pathology is traced mainly on the mother’s side.
The etiology of migraine.
Food rich in tyramine (cheese, red wine, cocoa, chocolate, smoked products, citrus, or nuts).
Irregular meal, especially starvation.
Psycho-emotional factors (emotional stress, depression, shock, frustration, and strong noise).
Physical factors (intense work, physical load); meteor conditions (cold, wind, and drafts).
Use of the hormonal contraceptives; menses.
Clinical factors (high BP or temperature, toothache, and allergy) and so on.
The pathogenesis of migraine.
The significant role is played by the hereditary inferiority of the vegetovascular regulation in the form of instability of the tone of extra- and intracranial vessels.
Disturbance of exchange of such biologically active agents as serotonin, catecholamines and estrogens, prostaglandins, kinins, histamine, substance-P, and vascular active peptides (vasointestinal peptide, calcitonin gene relating peptide).
The most popular is the trigeminal-vascular theory: the activation of the trigeminal nerve leads to the release of potent vasodilator from its nerve endings; it causes the decrease in the vascular tone with further development of the aseptic neurogenic inflammation, in which there is the increase in permeability of the vascular wall, its swelling, and also inflammation of the dura mater and meninges of the brain.
The aseptic inflammation provokes exaltation of afferent fibers of the trigeminal nerve, which anatomic features cause occurrence of the pain in a half of the head with the most frequent localization in the frontal-temporal-parietal area.
Classification of migraine.
There is the migraine without the aura (simple migraine) ; migraine with the aura (the associated migraine). The migraine with the aura is divided into:
migraine with the prolonged aura.
family hemiplegic migraine.
migraine with the aura without pain.
migraine with the acute beginning of the aura.
Children’s periodic syndromes, which may precede the migraine or are associated with it (the benign paroxysmal dizziness, alternating hemiplegia).
The status migrainous and migrainous infarct of the brain belong to the complicated forms of the migraine.
The clinical Picture of migraine attack.
In most cases the migraine occurs without the aura. At the same time the headache attack and vomiting is observed.
Quite often the attack is preceded by the prodromal stage, which is characterized by change of mood, nervousness, irritability, apathy, addiction to concrete food, especially sweet, frequent yawning, and depression of working capacity. This period lasts for several hours and is replaced by the headache, which is localized in the frontal-temporal-parietal area of one half of the head, has the throbbing character, gradually accrues with accession of vomiting at the pain height, and also with the photophobia and phonophobia.
The migraine headache often increases at any physical activity, coughing, sneezing, climb the stairs, with the head tilts down, or in other situations promoting the high intracranial pressure. Some patients have the vegetative disturbances: the dyspnea, sweating, pain in the epigastric area, diarrhea, frequent urination, orthostatic hypotension, and dizziness. During an attack the patient tries to squeeze the head (makes a dressing with a towel), or goes to bed in the dark room.
The “Aura” before the migraine attack.
The retinal migraine is manifested by the transient blindness on one or both eyes in combination with the headache (the discirculation in the system of branches of the central artery of the retina of the eye). In the hemiplegic migraine the transient mono- or hemiparesis with the hemiparesthesia or hemihypesthesia are formed.
The ophthalmoplegic migraine is the migraine, at which the headache is combined with the oculomotor disturbances, unilateral ptosis, or diplopia. In the basilar migraine the headache is followed by the tinnitus, dysarthria, and ataxia, paresthesia in the extremities, bilateral visual disorders, and dizziness. A short-term disturbance of consciousness is possible.
Complications of the migraine.
The status migrainous is the severe complication of the migraine. These are the migraine paroxysms occurring one after another, or one severe and long attack with repeated vomiting and possible development of the brain infarct.
The migrainous infarct is characterized by the presence of the focal neurologic symptoms depending on localization.
Diagnostics criteria of M.
For the diagnostics of the migraine without the aura in the history that to be not less than 5 migraine attacks corresponding to the following criteria: the duration of the paroxysm is from 4 to 72 hours;
mainly unilateral localization of the headache (alternating is possible: on the left, on the right); the throbbing nature of the headache, which increases at exercise stress;
existence at least one of the attack symptoms nausea, vomiting, photophobia, and phonophobia.
The treatment of the M. attack.
The modem preparations (used for the treatment of an attack) are the selective agonists of serotonin (Sumatriptan, Zolmitriptan, Rizatriptan), Sumatriptan (Imitrex, imigran) is used orally 50—100 mg, or subcutaneously — 6 ml (if necessary, the dose is injected repeatedly in 2 hours), or in the form of the transdermal Migraine Patch (NP 101 — Zelrix). Zolmitriptan (Zornig), as a rule, is used at the beginning of the migraine attack, the optimal dose is 2.5—5 mg.
In milder attacks they use acetylsalicylic acid and its derivatives in combination with caffeine-benzoate of sodium, non steroid anti-inflammatory drugs (Diclofenac potassium, Naproxen).
The status migrainous.
necessary to hospitalize the patient. Prescribe: Tramadol (tramal) 50—100 ml IV or Aspisol in a dose of 1000 mg IV in Bolus;
Butorphanol (Morada, Stadol) 1 mg IV; Torecan, Neuleptil, Navoban, and Haloperidol (in the repeated vomiting);
Seduxen — 0.5 % solution of 2—4 ml in 20 ml of 40 % solution of glucose is introduced IV; corticosteroids (Prednisone, Dexametha- zone — 8—12 mg per day),
neuroleptics (Aminazine); Metoclopramide;
antihistamines (Dimedrol, Suprastin, calcium gluconate)
The hemodilution due to dehydration.