Clinical Medicine and the Nervous System Series Editors: John P. Conomy and Michael Swash

Forthcoming titles in the series

Epilepsy: electroclinical syndromes _ Edited by Hans Liiders and Ronald P. Lesser

The Heart and Stroke Edited by Antony J. Furlan and John P. Conomy

Electrophysiological Diagnosis E. M. Sedgewick

Headache

Richard Peatfield

With 15 Figures

Springer-Verlag Berlin Heidelberg New York Tokyo

Richard Peatfield, MA, MD, MRCP Senior Registrar-Neurology General Infirmary at Leeds Great George Street, Leeds I West Yorkshire, UK

The illustration on the cover is taken from an original etching entitled 'The Headache' by George Cruikshank (1792-1878).

ISBN-13 :978-3-540-19531-3 e-ISBN-13 :978-1-4471-3127-4 DOl: 10.1007/978-1-4471-3127-4

The work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically those of translation, reprinting, re-use of illustrations, broadcasting, reproduction by photocopying, machine or similar means, and storage in data banks. Under § 54 of the German Copyright Law where copies are made for other than private use, a fee is payable to 'Verwertungsgesellschaft Wort', Munich.

© by Springer-Verlag Berlin Heidelberg 1986 Sollcover reprint of the hardcover 1st edition 1986

The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use.

Product Liability: The publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check its accuracy by consulting other pharmaceutical literature.

Filmset by Latimer Trend & Company Ltd, Plymouth

2128/3916-543210

Series Editors' Foreword

The rapid pace of advance in the basic and clinical sciences has led to striking changes in the practice of medicine. This is particularly evident in clinical neurology. Twenty years ago neurology was justly criticised for its preoccupation with diagnosis and classification, and for the relative paucity of treatments then available. All this has now changed, and neurology has become a treatment-oriented specialty. This change has been brought about partly as a result of the introduction of new and accurate methods of diagnosis, especially immunological, electrophysiological and imaging techniques, and partly as a result of new forms of treatment. Examples of these new treatments include the control of cerebral edema, new antibiotics for infections of the nervous system, drug level measurements for the evaluation of the adequacy of treatment of epilepsy and advances in neurosurgical technique. In addition, many patients presenting with neurological disorders are found to be suffering not from primary diseases of the nervous system but rather from neurological compli­cations of systemic disease. Vascular disease, cancer and infections are common examples. The degenerative disorders have recently become a focus of attention as their importance in the aging societies of the developed Western countries has been realised, and this raises the hope of improved management and treatment of these disorders.

Clinical Medicine and the Nervous System, a new series of short monographs, has been prepared in order to provide a readily available source of information about current views on practical management of patients with neurological disorders. This, the first volume in the series, is concerned with the commonest of all clinical problems in neurology, Headache. In this book Dr. Peatfield empha­sises the clinical approach to the symptom itself, and shows how a plan of management, investigation and treatment can be derived from this clinical data base. Basic mechanisms of headache are described insofar as they are relevant to clinical practice, and the

vi Series Editors' Foreword

various forms of treatment are discussed. Differential diagnosis is emphasised. Brief case descriptions are used to illustrate these concepts. The book is offered as a succinct source of reference for the management of patients presenting with headache. We believe that all neurologists and, indeed, all physicians concerned with the management of patients with headache will find Dr. Peatfield's book useful in their clinical practice.

Cleveland, Ohio London

John P. Conomy Michael Swash

Preface

Headache is one of the most common symptoms for which patients seek advice, both from hospital specialists and from general practi­tioners. This volume is intended to give an account of the assessment and management of such patients, drawn from personal experience both in general neurological clinics and in a specialist migraine clinic seeing patients from a wide area. The diagnosis of those causes of headache which can be established from the history or physical examination at initial clinical assessment is discussed in some detail, but greater emphasis is given to patients without any such clues to the aetiology of their pain. After the identification of the small minority of these who also have an organic or structural cause for their pain, there remain a large number of patients whose headaches are the result of poorly understood pathophysiological disturbances of the brain and/or other cranial structures. The bulk of the book is devoted to a discussion of the diagnosis and management of such patients and of what is known about the mechanisms of their distress.

The book is intended as a practical guide to be read by neurolo­gists, general physicians, and other doctors likely to see patients with headache. In addition it should function as a reference source to assist in the management of less straightforward patients, and for this reason includes discussion of a number of less common head­ache syndromes whose recognition is important.

Acknowledgements

I am particularly grateful to Dr. Michael Swash and to Mr. Michael Jackson and his colleagues from Springer Verlag for their helpful comments during the preparation of this text. Earlier drafts have been considerably improved as a result of the comments of Dr. John

viii Preface

Fozard, Dr. Simon Currie and Dr. Aidan Twomey, who have each read it in its entirety, and Dr. Vivette Glover and Mr. David Price, who have commented on individual sections.

I am grateful to Dr. Simon Currie, Dr. Bryan Ashworth, Dr. Michael Saunders, Dr. Roger Cull, Mr. Martin Rice Edwards, Dr. Louis Loizou and Professor M. Losowsky for providing details of patients they had seen. I am also grateful to Dr. Jonathan Chick and Dr. James Robertson for their guidance on the relationship between alcohol and headache and to Dr. Roderick MacFaul for help with migraine in children. The histological slide of temporal arteritis was provided by Dr. Alison McCartney, the operative photograph of trigeminal neuralgia by Mr. Robin Illingworth and the frontispiece by Mr. Andrew Edmonds. Most of the illustrations were drawn and photographed in the department at St. James's Hospital, Leeds.

Over many years I have been indebted to librarians at Charing Cross Hospital, The Royal Society of Medicine, Universities of Leeds and Edinburgh, Pinderfields Hospital Wakefield and the National Lending Library at Boston Spa. The text has been typed (and retyped) by Miss Joan Lennie in Edinburgh and the references by Mrs. Corinne Holmes in Wakefield.

Leeds, January 1986 Richard Peatfield

Contents

1 A Lot of Sufferers . . . . .

The Role of the Neurologist. Absenteeism from Work. References. . . . . . . . . . .

2 Disturbances of Structure and Function .

Classification of Headache. References. . . . . . . . . . . . . . . . . .

3 Approaching the Patient

History Taking . . . . Clinical Examination . When to Investigate. Reference ...... .

4 Organic Causes of Headache.

Intracranial Masses. . . . . . . Hydrocephalus . . . . . . . . . Arteriovenous Malformations . Pain from the Neck. Sinusitis ............ . Temporal Arteritis ...... . The Teeth and Temporomandibular Joints. Intracranial Vasodilation. Meningitis. . . . . . . . . . . . . . . . . . .

2 3 4

5

6 8

9

9 11 12 13

15

16 18 19 20 21 22 24 26 27

x

Subarachnoid Haemorrhage . Neuralgias. . . . . . Blood Pressure . . . Diseases of the Eyes Diseases of the Skull References. . . . . .

5 Miscellaneous Functional Headaches

Atypical Facial Pain . Cough Headache . . . Exertional Headache . Coital Headache . . . Lumbar Puncture Headache . Drug-Induced Headache . . . Food-Induced Headache ... Ethyl Alcohol-Induced Headache. References. . . . . . . . . . . . . .

6 Epidemiology of Headache.

Migraine and Personality. Headache and Depression References. . . . . . . . .

7 Clinical Features of Migraine and Other Headaches .

Sex Ratio ...... . Frequency of Attacks. Duration ....... . Nausea and Vomiting. Location of the Headache Aura Symptoms. . . . Inheritance. . . . . . . Long-Term Prognosis. Complications. . . . . Variants of Migraine . References. . . . . . .

8 Precipitating Causes of Migraine

Stress ............... . Hypoglycaemia ......... . The Female Reproductive Cycle. Food-Precipitated Migraine References ............ .

Contents

28 29 32 33 34 34

39

39 40 40 41 42 42 43 44 46

49

51 52 53

55

56 57 57 57 58 59 64 66 67 69 78

-: . 81

81 82 82 84 90

Contents xi

9 The Pathophysiology of Headache. 95

The Site of Origin of the Pain . . 95 Blood Flow Studies in Migraine. . 96 Catecholamines . . . . . . . . . . . 100 Disturbances of Platelet Function. 101 Opioid Peptides. . . 105 Neural or Vascular? 107 References. . . . . . 108

10 Treatment of Acute Headaches. 115

Nausea. . . . . . . . . . . . . . . . 115 General Principles of Analgesia . . 116 Non-steroidal Anti-inflammatory Drugs 117 Ergotamine . . . . . . . . . . . . . . . . 120 Other Drugs Used to Treat Established Headache. 122 References. . . . . . . . . . . . . . . . . . . . . . . 122

U The Prevention of Headache . . . . . 125

Sedative Agents. . . . . . . . . . . . . . 126 Non-steroidal Anti-inflammatory Drugs 127 P-Blocking Drugs. . . . . . . . . . . . . 127 Drugs Acting by Modification of Serotonin Function. 129 Drugs Acting on a-Adrenoceptors. 132 Calcium Channel Blockers. 133 Other Drugs in Migraine. 134 Which Drug? . . . . . . . 135 Miscellaneous Treatment. 135 Biofeedback . 136 References. . . . . . . . . 139

12 Cluster Headache. . 143

Clinical Characteristics . 144 Pathophysiology 148 Management 152 References. . . . 157

13 Post-traumatic Headache. . 161

Mechanism . . . . . . . . . . . 161 Role of Psychological Factors. 162 Post-traumatic Migraine. . . . 164

xii

Management of Post-traumatic Headache References. . . . . . . . . . . . . . . . . .

Contents

165 165

14 A Recapitulation. . . . . . . . . . . . . . . . . . . . . . . . 167

Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . 171