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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.

• 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

•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

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.

COMMON TYPES OF HEADACHES

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

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

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

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

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