Structures that do not cause pain in our head
Most of the dura (except the base of the skull)
Most of the brain parenchyma
Structures that cause pain in our head
Vessels
Leptomeninges
V., VII., IX. and X. Cranial nerves carry head and neck pain.
V. cranial nerve receives the sensation of the formations (anterior and middle fossa) above the cerebellar tentorium and the pain of this region is felt in the V. cranial nerve distribution.
Upper cervical nerves (1-2-3) receive sensation from infratentorial and cervical structures. Therefore, posterior fossa pain is felt in the 2nd and 3rd cervical nerve dermatomes.
Primary Headaches
Tension Type Headache
• It is the most common headache.
• Characteristically, it is a pressure-type headache, which can be widely seen on both sides of the head or in the cranium. It does not restrict routine physical activity.
• Photo-phonophobia (discomfort from light and sound) is not accompanied, there is no nausea and vomiting, it does not increase with movement.
It is more common in women; however, there is no significant difference between men and women as in migraine.
Migraine
• It is 3 times more common in women and most of them have a family history of migraine.
• It is usually characterized by unilateral pulsatile headache, nausea-vomiting, photophobia, phonophobia.
• It may cause restriction in the daily physical activity of the person.
• Its pathology has not been fully elucidated.
a) Migraine without aura
It is the most common type of migraine.
It takes 4-72 hours.
Migraine without aura is usually unilateral and throbbing.
There are no prodrome symptoms and no aura.
It is accompanied by nausea, vomiting, photophonia, phonophobia, worsening with physical activity.
b) Migraine with aura
1) Migraines with typical aura:
- Aura manifests itself with attacks of focal neurological symptoms lasting between 5-60 minutes.
- The most common aura type is visual symptoms. The most common scintilaston scotoma is seen.
- No engine weakness.
2) Hemiplegic migraine:
- In migraine with aura, if motor weakness accompanies the patient, hemiplegic migraine is present; It takes 5-60 minutes.
3) Basillary type migraine:
- The headache is usually in the occipital and is severe. Aura lasts 10-45 minutes.
- Complete blindness and accompanying it; It begins with vertigo, ataxia, dysarthria, tinnitus and perioral paresthesia.
- Brain stem findings are dominant.
c) retinal migraine
Headache is accompanied by symptoms such as photopsia in one eye and loss of vision.
d) Ophthalmoplegic migraine
It usually starts in childhood.
Unilateral, retroorbital headache is accompanied by vomiting for 1-4 days.
Pain is accompanied by ipsilateral ptosis and third cranial nerve palsy.
e) Chronic migraine
It is defined as migraine attacks more than 8 times a month and painful 15 days of the month.
f) Status migrenosus (migraine status)
It is used for migraine lasting longer than 72 hours.
Trigeminal-autonomic Type Headache
a) Cluster (cluster type headache)
It is the most common headache after migraine and tension headache.
It is more common in men between the ages of 20-40 and smokers.
The characteristic of the pain is that it is one-sided, very severe and short-lived.
It is thought that the trigeminal parasympathetic reflex is activated and causes sympathetic dysfunction.
Orbital, supraorbital, temporal unilateral severe headache that lasts 15-180 minutes every other day or can be seen 8 times a day.
Autonomic Findings;
Partial Horner syndrome (miosis, ptosis)
Nasal congestion, runny nose
Eye tear
Conjunctival blood supply
Increased forehead and facial sweating
Systemically; bradycardia, hypertension, increase in gastric secretion production
Attacks can last for weeks or months, with periods of recovery lasting months or years. It is separated by the attack period (pains clustered to certain time periods).
Treatment: 5-8 Lt oxygen inhalation in acute attack, triptan, dihydroergotamine, Corticosteroids can be used.
Verapamil, lithium and steroids can be tried prophylactically.
b) Paroxysmal Hemicrania
It is more common in women between the ages of 25-40.
The pain is always severe on the same side, lasts for a short time, and is a non-remission headache.
It is often seen as chronic, episodic form has also been described.
Pain can be defined as throbbing, piercing
Attacks can be between 5-20 times a day, the duration of pain is between 2-45 minutes.
Autonomic symptoms are very similar to cluster headache.
Typical feature is that it can be fully controlled with indomethacin.
c) SUNCT
Unlike other pains, it occurs in advanced ages. The average age of onset is 50.
Pain; burning, carving, electric shock.
It comes in attacks lasting 5-240 seconds. 3-200 attacks can be seen per day.
Headache and autonomic functions are encountered.
In some patients, stimulation of the trigeminal branches can be triggered by chewing or pressure.
Other Rare Primary Headaches
Hypnic headache:
• They are moderately severe headaches that typically occur a few hours after falling asleep at night and last up to 30 minutes.
• Patients with this type of headache usually respond to 200-600 mg of lithium carbonate taken at bedtime.
Primary stabbing headache:
• temporary and local pain fixations that occur spontaneously in the head without an organic disorder of underlying structures or cranial nerves.
atypical facial pain
• Persistent idiopathic facial pain without any finding on examination.
• It is a poorly understood condition with deep or superficial, usually unilateral, peripheral neuroanatomical borders, diffuse and mild subjective sensory complaints added to it.
Cranial Neuralgias
It is an acute, stabbing or constant pain in the area innervated by the trigeminal, glossopharyngeal, vagal, and occipital nerves in the head and neck.
Trigeminal neuralgia is the most common.
Pain is unilateral, short lightning-like in character.
It can usually be triggered by shaving, face washing, smoking, talking, and tooth brushing.
Small trigger points may be found in the nasolabial groove and chin.
Pain never crosses to the other side.
Spasm may develop in the facial muscles of that side during pain (painful tic).
Analgesics are ineffective in treatment.
Antiepileptics; carbamazepine, gabapentin, pregabalin can be used.
Secondary Headaches
Secondary Headache
• Head trauma
• Cranial or cervical vascular diseases
• Infectious headache
• Headache due to homeostasis disorder
• Headache due to psychiatric diseases
• Skull, neck, eye, ear, sinus, tooth, etc.
• Associated with non-vascular intracranial diseases
Depends on CSF pressure elevation
Due to low CSF pressure,
Intracranial neoplasms
Associated with epileptic seizures
Subarachnoid Hemorrhage
• Patients; They describe it as "the first, most severe, and worst headache in my life."
Giant Cell Arthritis (Temporal Arthritis)
• It is usually over the age of 50 and is twice more common in women.
• The external carotid artery system, especially the temporal artery, is involved.
• It is often associated with polymyalgia rheumatica complex.
• Pain occurs with jaw movements. --- claudication of the jaw---
• Temporary blindness due to ophthalmic artery involvement may occur in 50% of patients without treatment.
• However, blindness is usually permanent and does not improve.
• The diagnosis is made by taking a biopsy from the affected artery.
• ESR increased (100 mm/h).
• Initial treatment is steroid.
• The most important cause of optic neuritis over the age of 70 is temporal arteritis.
Intracranial Masses
• Space-occupying lesions do not cause headache until they press on pain-sensitive formations in the head.
• Pain typically increases with maneuvers (coughing, straining, etc.) that increase intracranial pressure.
• Headache is classically greatest when waking up in the morning and is accompanied by nausea and vomiting.
Idiopathic Intracranial Hypertension (Pseudotumor Cerebri)
• It most often develops idiopathic
• Most patients are obese.
Lumbal Puncture Pain
• Headache that typically resolves when lying down in patients with a history of LP. It gets worse while standing.
• It occurs 24-48 hours after the procedure and lasts for 4-5 days.
Medication Overuse Headache
• Headache due to overuse of drugs is secondary headache that develops due to taking ergotamine, triptan, simple analgesics, opioids, combined analgesics more than 10-15 days a month.
• There is no typical clinical picture, there is usually a primary headache such as migraine.
