Headache
Introduction
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.
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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.
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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:
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Intracranial masses such as brain tumors almost always cause some abnormality on the
neurologic examination by the time they cause headache.
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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
Muscle Contraction Headache
(Tension Headache)
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.
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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.
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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.
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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.
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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.
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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.
Migraine
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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
Final Notes
Remember, with all patients obtain information about timing and frequency of the
headache, location, quality of pain, precipitating events and associated complaints.
Dont 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.
Originally written by CAPT Terrance Riley, MC, USN. Revised by CAPT J. F.
Morales, MC, USN, Neurology Specialty Leader, Department of Neurology, National Naval
Medical Center, Bethesda, MD (1999).
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Preface
· Administrative Section
· Clinical Section
The
General Medical Officer Manual , NAVMEDPUB 5134, January 1, 2000
Bureau
of Medicine and Surgery, Department of the Navy, 2300 E Street NW, Washington, D.C.,
20372-5300
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