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Cla
ssifi
cati
on o
f H
eadach
e
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PAIN SENSITIVE PARTS OF CRANIUM
Our understanding of headache has been augmented by observations made during operations on the brain (Ray and Wolff).
• skin, subcutaneous tissue, muscles, extracranial arteries, and periosteum of the skull;
• delicate structures of the eye, ear, nasal cavities, and paranasal sinuses;
• intracranial venous sinuses and their large tributaries, especially pericavernous structures;
•parts of the dura at the base of the brain and the arteries within the dura, particularly the proximal parts of the anterior and middle cerebral arteries and the intracranial segment of the internal carotid artery;
•the middle meningeal and superficial temporal arteries; and
• the optic, oculomotor, trigeminal, glossopharyngeal, vagus, and first three cervical nerves.
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• Interestingly, pain is practically the only sensation produced by stimulation of these structures;
• the pain arises in the walls of blood vessels containing pain fibers
• Much of the pia-arachnoid and dura over the convexity of the brain, the parenchyma of the brain, and the ependyma and choroid plexuses lack sensitivity
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•pain from supratentorial structures is referred to the anterior two-thirds of the head, i.e., to the territory of sensory supply of the first and second divisions of the trigeminal nerve;• pain from infratentorial structures is referred to the vertex and back of the head and neck by the upper cervical roots
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MECHANISMS OF CRANIAL PAIN
• intracranial mass lesions cause headache only if they deform, displace, or exert traction on vessels and dural structures at the base of the brain• Dilatation of intracranial or extracranial arteries (and
possibly sensitization of these vessels), of whatever cause, is likely to produce headache. The headaches that follow seizures, infusion of histamine, and ingestion of alcohol are probably all caused by cerebral vasodilatation. Nitroglycerin, nitrites in cured meats ("hot-dog headache"), and monosodium glutamate in Chinese food may cause headache by the same mechanism.
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COMMON TYPES OF HEADACHES
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type site Age and sex
Clinicalcharacteristics
Diurnalpattern
Lifeprofile
Provokingfactors
Associatedfeatures
Migrainewithout aura(commonmigraine)
Frontotempor
al
Uni- orbilateral
Adolescents,
young tomiddle-agedadults,sometimeschildren,morecommon inwomen
Throbbing(pulsatile);worse behindone eye or Ear Becomes dullache andGeneralize
Scalp sensitive
Uponawakeningor later inDayDuration: 4–24 h in mostcases,sometimesLonger
Irregularintervals,weeks toMonthsTends todecreasein middleage andduringPregnancy
Brightlight,noise,tension,AlcoholRelievedbydarknessand sleep
Nausea andvomiting insome cases
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type site Age and sex
Clinicalcharacteristics
Diurnalpattern
Lifeprofile
Provokingfactors
Associatedfeatures
Migraine withaura(neurologicmigraine)
Same as above
Same as above
Same as above
Same as above
Same as above
Same as above
Scintillatinglights, visualloss, andScotomasUnilateralparesthesias,weakness,dysphasia,vertigo, rarelyconfusion
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type site Age and sex
Clinicalcharacteristics
Diurnalpattern
Lifeprofile
Provokingfactors
Associatedfeatures
Cluster(histamineheadache,migrainousneuralgia)
Orbitotemporal Unilateral
Adolescentand adultmales(90%)
Intense,nonthrobbing
Usuallynocturnal,1–2 h afterfallingAsleep
Occasionallydiurnal
Nightly ordaily forseveralweeks toMonths
Recurrenceafter manymonths oryears
Alcohol insome
Lacrimation
Stuffed nostril
Rhinorrhea
InjectedConjunctivum
Ptosis
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type site Age and sex
Clinicalcharacteristics
Diurnalpattern
Lifeprofile
Provokingfactors
Associatedfeatures
Tensionheadaches
Generalized Mainlyadults, bothsexes, morecommon inwomen
Pressure(nonthrobbing),tightness,aching
Continuousvariableintensity, fordays, weeks,or months
One ormoreperiods ofmonths toyears
Fatigueandnervousstrain
Depression,worry,anxiety
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type site Age and sex
Clinicalcharacteristics
Diurnalpattern
Lifeprofile
Provokingfactors
Associatedfeatures
Meningealirritation(meningitis,subarachnoidhemorrhage)
Generalizedorbioccipital, orbifrontal
Any age,both sexes
Intense, steadydeep pain, maybe worse inneck
Rapidevolution—minutes tohours
Singleepisode
None Neck stiff onforwardBending
Kernig andBrudzinskisigns
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