Headache

Department of the Navy
Bureau of Medicine and Surgery

Headaches may be the most common complaint in medical practice. The operational medical officer must recognize when consultation is necessary, and know the principles of transport for patients with severe neurological conditions. The first and most critical distinction is between acute or new headaches and those that are chronic or recurrent. Acute or new onset headaches are urgent medical problems until proven otherwise. The physician should keep a few general principles in mind. Gather a complete history, and perform a basic neurological examination. These basic steps will distinguish acute headaches that are emergencies until proven otherwise, from chronic headaches that call for reassurance and non-urgent treatment for the patient.

Subarachnoid Hemorrhage (SAH)

The spontaneous rupture of a saccular (berry) aneurysm usually causes bleeding into the subarachnoid space. The most common sites are around the Circle of Willis at the base of the brain frequently occurring at the junction of large to mid-sized intracranial arteries. These hemorrhages are sudden and catastrophic; nearly half of patients die within the first day. Most patients fall or collapse, and those who survive, refer to it as "the worst headache of their life". Ten to fifteen percent of cases have a seizure at or shortly after the hemorrhage.

• The sudden explosive onset of "the worst headache of my life" should indicate subarachnoid hemorrhage until ruled out otherwise. A computed tomography (CT) scan is most sensitive in diagnosing this condition. However, if scanning is not available, lumbar puncture is adequate and must be performed. The spinal fluid will look like fresh blood after a subarachnoid hemorrhage, but it usually will not clot. If the bloody CSF is spun in a centrifuge, the supernatant fluid will remain blood colored because hemolysis in the spinal fluid will have released hemoglobin into solution.

• Treatment of SAH begins with the ABCs. If consciousness is suppressed, the patient may need to be intubated. Supplemental oxygen will be required, because arterial spasm, beginning on the second and third day, will likely impair cerebral perfusion, so the highest possible oxygen tension is desirable. Heart block and arrhythmias may result from autonomic effects of cortical irritation, so constant cardiac monitoring is required.

Chronic or Recurrent Headaches

For chronic or frequently recurring headaches, it seems that the general public worries most about brain tumors or other masses. Here are two reliable rules of thumb for the general medical officer:

• Intracranial masses such as brain tumors almost always cause some abnormality on the neurologic examination by the time they cause headache.

• Tumors seldom cause very severe headaches. Confronted with an otherwise healthy young patient complaining of a severe headache, many young physicians worry about missing a brain tumor. However, if the pain is very bad, especially causing sharp pain, and if the neurological examination is normal, it is unlikely to be significant neurological disease. While it is necessary to follow the patient, often with serial examinations, neither the doctor nor the patient should be intimidated by the unreasonable fear of a tumor. Emergency evacuation for a head CT scan is seldom justified in this setting

By far, the most common cause of headaches is muscle contraction. The typical distribution of the pain is around the temples and the occiput. The frontalis muscle is often involved causing a frontal headache as well. A muscle contraction headache typically proceeds as the day progresses and tends to worsen in the afternoon. A throbbing quality is less common than in a migraine headache, but may be a feature, as the headache grows more severe.

• The term tension headache was first applied to the muscle contraction headache because of the role of muscle tension. Emotional tension may provoke neck spasm and tension of nuchal and facial muscles. The pathogenesis is due to muscular spasm. It is misleading to consider muscle contraction headache as merely a sign of stress. On examination, the tightness of the cervical muscles and tenderness over the muscle mass of the temporalis may assist in making the diagnosis.

• The pain from muscle contraction headache can be severe. Most people with daily headaches have muscle contraction headaches. In these patients, consider cervical spine problems, and explore their work positions, and general posture.

• Diagnostic studies are usually not necessary for muscle contraction type headaches. For patients with significant cervical spasm and daily headaches, cervical spine x-rays may be useful.

• The treatment of a muscle contraction headache begins with aspirin, acetaminophen, or a nonsteroidal anti-inflammatory (NSAID). Doses of NSAIDs, such as ibuprofen 2400 mg/d may be necessary for more severe cases. If the headaches are frequent, treatment should be addressed to the underlying cause. First determine if there is a predisposing postural or work related cause. Adjusting the height of a work surface, pillow in bed, or sitting position may reduce the spasm that causes the headaches.

• Heat is a useful treatment in many patients. Increasing physical exercise can reduce the muscle strain pattern; stretching and aerobic exercises are the best. Biofeedback or treatment of an underlying stressful situation may be necessary in certain situations.

Next to muscle contraction, migraine is the most common type of headache. As many as 15 percent of the general population have recurring migraines, and well over half of the population will experience a migraine attack sometime during their lives.

• A migraine, described as a unilateral, throbbing type headache, can last from at least 30 minutes up to many hours. It is less common for true migraines to last more than 24 hours. In most people, the attacks seem to occur in batches, with several bad attacks over a week or two. (Be careful of terminology with headaches that recur in groups. There is a specific syndrome called Cluster Headache - see below - which is a distinct clinical entity, not just clusters of migraines.) Migraines have a diurnal pattern. They occur more often in morning than afternoon or evening, and often present on awakening. A migraine may even awaken a patient at night. This is in contrast to muscle contraction headaches that develop over the course of a day, usually in the afternoons or evenings. The patient with a migraine usually prefers to be alone in a dark quiet place and the headache is frequently relieved with a short nap.

• In the classical migraine type of headache, the patient has a prodrome, (which is the early stage of the attack) lasting several minutes to several hours. For some patients, this is an uncomfortable feeling, which they recognize to be a warning. Most classical migraine prodromes are visual in nature. Scintillating scotoma, the visual symptoms usually occupying one visual field, are described as elaborate zig-zag patterns, flashing lights, crescents, or other patterns. Gastrointestinal symptoms most often accompany or follow the headache.

• Migraines usually begin during adolescence and not uncommonly in childhood. Frequently attacks diminish or disappear in the early twenties age group and return unexpectedly in the thirties age group. These may appear as a new onset headache attack. In all cases, the physician should inquire about any migraine qualities as well as past history of headaches.

• There is a definite chemical and dietary aspect in migraine headaches. Certain foods rich in nitrites or certain amino acids provoke attacks in many patients. Some products include preserved meats, chocolate, tyramine in some aged cheeses, and spices such as monosodium glutamate. Alcohol, especially beer and red wines, are provocative for other patients. Successful migraine treatment includes dietary counseling for all patients. In some cases a small number dietary adjustments can control attacks.

• Aspirin 650 mg every four hours, is effective for some patients. The second order medications are NSAIDs such as ibuprofen. These are effective in about half of patients. The stalwart in migraine is ergotamine tartrate, 2 mg by mouth or per rectal suppository at the onset of attack, and can be repeated to a maximum total dose of 6 mg over a 24-hour period. Dihydroergotamine (DHE) could also be used in a nasal spray form. Ergotamine is a potent vasoconstrictor and is contraindicated in hypertension or coronary artery disease. It is also a smooth muscle contractor, and has been known to cause intolerable stomach cramps and nausea in some patients. Various forms of Sumatriptin are presently available; self injection for subcutaneous administration, oral tablets (25mg and 50mg), and nasal spray. Sumatriptin is effective in 70 to 80% of cases. Remember that it is a potent vasoconstrictor so it should be used judiciously. Avoid using in any patients with evidence of coronary artery disease.

For those patients who have more than 4 severe attacks per month, preventive medication may be advisable. First line therapy is aspirin (ASA). Doses of ASA 325 mg every morning may significantly reduce frequency and severity of attacks in 25 percent of patients. Beta-blockers such as propranolol, atenolol, or metoprolol, in doses used to treat hypertension, are useful in some patients. The majority of patients can control their headaches to no more than two a month with diet or preventive medications (NSAIDs or ergotamine).

Narcotics should never be used for migraines. It is a chronic condition, which will recur over many years and the combination of adaptation, and preventive medications should be tailored for each patient.

True migraine is disqualifying for flight and several other special duties in the military, primarily because of the risk for visual disturbance. According to the Manual of the Medical Department, severe or disabling migraine is disqualifying for naval service. If a patient fits into any of these categories, the GMO should consider referral to a medical board or operational specialty such as diving medical officer or flight surgeon.

Cluster Headache

Cluster headache is a unique clinical entity related to migraine but less common in frequency. It occurs more often in men than women, and causes a stereotypical, excruciating pain behind the eye. Attacks are always exactly alike, even if separated by many years.

• Pain is usually of a sudden onset, occurring very late at night, and can last from 30 to 90 minutes. The conjunctiva on the affected side is red, the eye tears copiously, and there may be ptosis and slight meiosis in the pupil. The attacks come several nights every week during the course of a cluster that can last for 2 to 6 weeks, seldom longer. The clusters disappear and may not recur for many years, but when they do, the patient recognizes them instantly.

• There is no proven therapy for cluster headaches. Initial therapy should include 100 percent oxygen by face mask initially since this provides good relief in many patients. Because of the short-lived nature of episodic cluster headaches, narcotics are not indicated for management. Methysergide, 8 mg per day in divided doses, seems to reduce the severity in most patients, but gastrointestinal side effects make it intolerable for a third of patients. In this author's opinion, nothing yet discovered works for cluster headache.

Remember, with all patients obtain information about timing and frequency of the headache, location, quality of pain, precipitating events and associated complaints. Don’t forget to test for cerebellar function and gait. If focal neurologic findings are found referral is necessary. Arrange for adequate follow-up, document treatment instructions, and ensure the patient understands the treatment plan.