Headache is a very common reason for medical consultation. Most often the cause is benign. Yet receive a patient Headache is always a problem, the range of causes is extremely broad, ranging from potentially very serious situations mundane and benign causes.
So we must first, think of the serious causes that delays in diagnosis could have significant consequences. Are we sure of having completely eliminated and gave it the means to do so?
then it is necessary to know the characteristics of some simple tables. Often, more rare causes of headaches are merely variants of these key tables.
Finally, a number of misconceptions about headache should be dropped.
Analysis of headache is the first time essential. It is based on the interrogation:
– How did the headache started, gradually or suddenly: a sudden onset of headache evokes first subarachnoid hemorrhage?
– Under what circumstances, eg, headache occurring only orthostatic immediately evoke an intracranial hypotension mechanism?
– What is its evolution over time: only by crises or ongoing? What is the duration of a crisis, what is the frequency of seizures and temporal profile?
– What is the length of the headache, is an acute episode, new and possibly unique, there is a chronic or remittent character?
– What treatments have been tried?
– There are accompanying signs?
– Fever, nausea and vomiting, photophobia,
– Vegetative phenomena: conjunctival injection, eye discharge, nasal congestion, rhinorrhea, ptosis, eyelid edema?
The clinical examination is of course complete, and often supplemented by further examination, usually a brain imaging.
Misconceptions and errors:
Some misconceptions and errors are typically source of misdiagnosis:
– Headache, high blood pressure: outside the very specific case of hypertensive acute encephalopathy, hypertension does not give headaches.
– Neuralgia Arnold: This is classically unilateral occipital pain radiating to the frontal region. In fact, this type of headache is more to other mechanisms (migraine, tension headache, or arterial dissection or intracranial expansive process) that presumed mechanism of occipital neuralgia whose reality remains to be seen.
– Report too easily to a hypothetical sinusitis headache a different origin.
Other misconceptions and mistakes could of course be listed. These occur less frequently if you always think in the management of the patient Headache, large tables set out below, and if in doubt, the necessary complementary examinations are performed or requested expert advice.
Serious causes of headaches are always considered before stopping a diagnosis of benign headaches. In case of doubt, additional tests needed to remove this doubt is to achieve.
* Clinical picture:
The subarachnoid hemorrhage is diagnosed to evoke principle before any sudden onset of headache, regardless of its intensity, its duration or its associated signs. It occurs on the occasion of an effort by a severe headache accompanied by photophobia, with, for consideration, a tendency to drowsiness and a stiff neck. Between 20 and 50% of patients who had a documented subarachnoid hemorrhage report the existence of one or more episodes of unusually brutal headaches in the days or weeks.
These headaches called “sentinels” are still of sudden onset, reaching maximum intensity within minutes and can last from hours to days.
Confirmation of the diagnosis subarachnoid hemorrhage is much easier that examinations are made early. The brain scan confirmed the subarachnoid hemorrhage with a sensitivity of almost 100% if performed within 12 hours after installation of the headache.
This sensitivity drops to 90% in 24 hours and around 50% after one week. If negativity or impossibility to perform a scan, lumbar puncture showed subarachnoid hemorrhage. However it is sometimes difficult to differentiate a subarachnoid hemorrhage fluid from a lumbar puncture (LP) traumatic (about 20% are traumatic PL) and the liquid becomes usually normal in a few weeks. If the patient is seen in more than a week of the episode, the normality of the scanner and the PL does not exclude the diagnosis and MR angiography of the intracranial arteries must be performed without delay.
Etiology and differential diagnosis:
The etiology is dominated by the rupture of vascular malformations, mainly arterial aneurysms, arteriovenous malformations rarely. Yet 25% of patients with documented subarachnoid hemorrhage were initially raised another diagnosis. This is all the more regrettable that the risk of information after subarachnoid hemorrhage is maximum in the following week, and that a delayed diagnosis thus exposed to fatal or serious neurological sequelae.
Much more rarely, the brutal headache may be the result of cerebral venous thrombosis or carotid dissection.
The brutal headaches can be idiopathic ( “thunderclap headache”), related or not with an effort. This diagnosis should not be accepted with great caution.
The therapeutic management of subarachnoid hemorrhage is of course variable depending on the cause. The treatment of vascular malformations based on interventional angiography and surgery, more rarely stereotactic radiotherapy in the case of arteriovenous malformations small.
* Clinical picture:
Intracranial pressure (ICP) is to raise with any recent headache, progressive, daily, possibly associated with nausea and / or vomiting, aggravated by physical effort.
The finding of abnormalities in the neurological examination, mental slowing, somnolence or papilledema on fundus allows the recall immediately. The finding of a normal eye bottom may be falsely reassuring. It is indeed rare that papilledema is present in cases of intracranial hypertension in the elderly.
Doubt leads to the production of a brain imaging (CT or MRI) can immediately show the cause of the HIC (intracranial expansive process, intracranial hematoma, hydrocephalus) or indirect evidence suggesting the existence of an HIC .
The therapeutic management of intracranial hypertension is that of his cause.
* Clinical picture:
The diagnosis of meningitis is immediately evoked in a febrile patient with recent and intense headache, nausea / vomiting and a stiff neck for the exam.
Think of meningitis becomes more difficult as the initial symptoms are discreet, with moderate headache, little or no nausea / vomiting, a little feverish train.
Sometimes these symptoms will not always specific property led to the prescription of antibiotics in the event of a sinus pathology or infection of the upper airways and the problem of a possible bacterial meningitis decapitated be installed.
The search still reviewing evidence for fulminant meningococcemia and the patient is admitted to emergency for lumbar puncture or not preceded by a brain imaging examination and context.
In the event of an abscess or encephalitis, achieving Emergency lumbar puncture is necessarily preceded by brain imaging.
The clinical, CSF analysis and biology make it easy to differentiate bacterial meningitis from viral meningitis or tuberculous meningitis.
The therapeutic treatment depends on the cause and not started until after the results of the lumbar puncture.
The only exception is the suspected meningococcemia (purpura) that begin without delay antibiotic treatment (currently ceftriaxone).
Viral meningitis does not demand any treatment other than supportive.
Cerebral venous thrombosis:
* Clinical picture:
There is no typical picture of the cerebral venous thrombosis. Headaches are extremely common, which may be intense and may be the only manifestation. They can be of sudden onset and evoke from subarachnoid hemorrhage. It may be associated nausea and other symptoms that may suggest increased intracranial pressure. Cit usually a neurological challenge sets in, often subacute way, frequently bilateral.
Seizures may occur.
The diagnosis is often mentioned because the context (pregnancy, postpartum, blood disorders, disorder of hemostasis, inflammatory disease).
MRI is the investigation of choice to show at once thrombosis venous sinuses and parenchymal echo.
Therapeutically, it is accepted that anticoagulant therapy improves patient outcomes.
Cervical artery dissection:
Carotid dissection is immediately suspected in a lateralized neck pain radiating to the hemicranium associated with a syndrome of Horner on the same side and a neurological deficit contralateral side of the body.
Nevertheless, the picture is not always as complete.
The vertebral dissection is rare and associated neck pain rather posterior, posterior headache and signs of vertebrobasilar ischemia.
It is accepted that the dissection of extracranial cervical arteries belong, in the acute stage, anticoagulant therapy in the absence of indication-cons (hemorrhagic infarction, myocardial large volume, etc.).
* Clinical picture:
Horton’s disease should be suspected in principle in any patient over 60 years complaining of headaches. These are of recent onset, usually temporal and associate with an impaired general condition (fatigue, weight loss, fever). The severity of GCA is its visual complications with the risk of occurrence of acute ischemic optic neuritis may lead to loss of vision in one or both eyes rapidly.
Wanted existence of a jaw claudication, a sign of the reed, the symptoms of polymyalgia rheumatica associated visual signs.
The examination may show induration or not swinging temporal arteries. Laboratory tests shall above all elevated sedimentation rate and elevated CRP, knowing that this element can sometimes fail to start.
The diagnosis is confirmed rapidly by the bilateral temporal artery biopsy.
As soon as the diagnosis is suspected, treatment with corticosteroids is begun. The starting dose is 0.7 mg / kg / day is increased to 1 mg / kg / day in case of visual impairment. there is associated with calcium, vitamin D, and biphosphorate.
We follow the effectiveness of treatment on the rapid regression headache, the CRP and fibrin. We can then reduce prednisone,
quickly to the landing of 20 mg / day, then more slowly. The total duration of treatment is at least one year.
* Clinical picture:
Migraine is the prototype of the recurrent headache.
It usually lasts a few hours, often unilateral, throbbing, associated with nausea / vomiting, photophobia, sonophobie, exaggerated by the effort.
Migraine is sometimes preceded by an aura, visual, sensory or as language disorders, sometimes a combination of these symptoms.
The frequency of attacks is extremely variable.
The diagnosis is obvious when the criteria for recurrence and characteristics of headache are typical. The diagnosis is more difficult when crises are rare, the aura is long, intricate the headache when the headache is very quickly from high intensity, suggesting it could be a subarachnoid hemorrhage.
* Differential diagnosis:
For all these reasons, the doubt exists sometimes with a subarachnoid hemorrhage, intracranial hypertension headache, cerebral venous thrombosis, carotid dissection.
In these cases, additional tests to exclude these diagnoses are implemented without delay.
Therapeutically, we must distinguish the handling of the crisis and treatment of substance.
* From crisis:
We distinguish, in the treatment of the crisis, non-specific treatments and specific treatments.
The non-specific treatments are the usual analgesics (paracetamol, aspirin, various associations) and nonsteroidal anti-inflammatory drugs.
Specific treatments are represented mainly by triptans. Derivatives of ergot are hardly used.
Good treatment of the crisis must ensure, with a well tolerated single intake, quick relief and a non-recurrence of pain.The use of NSAIDs as first line followed in case of non-relief at 2 hours, taking a triptan is a logical alternative in case of inefficiency of aspirin or paracetamol.
We begin immediately by the triptan in case of inefficiency of NSAIDs. Several triptans are tried before concluding the ineffectiveness of this drug class.
The basic treatment is only justified in cases of frequent attacks. Below 4 attacks per month, making such treatment probably does not justify himself. Various products are available in this indication with efficacy, tolerance and variables against-indications (propranolol, metoprolol, dihydroergotamine, pizotifen, oxetorone, amitriptyline, flunarizine).
Tension headaches and other chronic daily headache:
These headaches are happy everyday, but the characters of migraine. The headache is often posterior, more type tightness
that pulsatile, rarely of high intensity, usually without nausea or vomiting, often associated with neck pain and feelings of instability.
These headaches often occur in periods of fatigue or nervous tension among major usually anxious subjects.
This diagnosis is retained once other causes of headache excluded with certainty.
Besides tension headaches, one must distinguish chronic migraine and headaches by abuse of painkillers.
It uses paracetamol in first intention, and on failure to amitriptyline in small doses.
* Clinical picture:
The trigeminal neuralgia is a facial pain more than a headache.
The pain is unilateral and only seat in the path of one of the branches of the trigeminal nerve (mandible, maxilla or more rarely ophthalmic).
Pain is dazzling, like an electric shock, very short but sometimes burst.
It is often triggered by the excitement of an area of skin or mucous, touch a face region, shaving, chewing, swallowing.
The exam is normal. Any atypical symptomatology or any abnormality in the review raises the question of secondary neuralgia.
It is in any case difficult to do without a brain MRI. This allows to definitively rule out a secondary neuralgia by eliminating a tumor lesion, vascular or an inflammatory disease of the nervous system.
In essential neuralgia, MRI can sometimes highlight a neurovascular conflict between the V and vascular loop in the posterior fossa.
Mostly carbamazepine is remarkably effective on pain. Gabapentin is a possible alternative.
It is rare that the essential neuralgia is resistant to medical treatment. Sometimes the patient is relieved but the significant adverse effects price. In these cases, we can offer a thermocoagulation of the trigeminal ganglion.
The first live trigeminal in the posterior fossa with microvascular decompression in case of neurovascular conflict is a heavy machinery, not devoid of risks and indications should be carefully considered.
Cluster headache face:
* Clinical picture:
The cluster headache (AVF) is a special table.
Pain is strictly unilateral, in the orbital region. It occurs in about one hour crises. It is extremely violent.
It is most often associated with vegetative signs type watery eyes, runny nose, conjunctival injection. One or more attacks may occur in the day.
The AVF occurs by painful periods.
During these times, the seizures occur one or more times per day, every day without exception (except at the beginning and end of period) for a period of several weeks.
This diagnosis is applied only if the painting is typical. Any atypia should do at least temporarily and to reject the question of a dissection or carotid thrombosis in particular.
The exam is normal.
The usual analgesics are ineffective during the crisis. Sumatriptan alone subcutaneously provide rapid relief to patients.
The bottom of verapamil treatment is usually effective. Methysergide is less consistently effective, compatible with an eventual treatment of the crisis by sumatriptan and exposed to rare but serious adverse events (pulmonary fibrosis or retroperitoneal).
Lithium, corticosteroids have been proposed DMARD with a very inconsistent efficacy and significant side effects.
Headache intracranial hypotension:
* Clinical picture:
The intracranial hypotension headache is a schematic picture of a post-dural-puncture headache in an individual who has not suffered.
Headache is strictly postural, quickly disappearing while lying to reappear again quickly when standing or even sitting.
It may be associated neck pain, the existence of dizziness, tinnitus, diplopia standing.
Such a table results from the existence of a gap at the lumbar spine meninges most often breach can occur either spontaneously or after an effort.
Brain MRI is suggestive of this diagnosis, showing a contrast enhancement of the meningeal system associated with signs reflecting the trend of lowering the brain to the foramen magnum.
Treatment is based on the blood patch.
Headache or facial pain acute or subacute in connection with a local affection:
Whether otitis, sinusitis, dental injuries, glaucoma, they are usually quickly detected.
Treatment relies on antibiotics in case of infection ENT and eye drops to beta blockers for glaucoma.
In general, less common causes of headache realize variations tables described above.
You can classify them according to their circumstances of appearance and their temporal profile.
Other headache of sudden onset:
Their model is the headache of subarachnoid hemorrhage.
Consider the following be sure to have reasonably eliminated subarachnoid hemorrhage.
Thunderclap headaches, coital, effort:
They all have in common to have a sudden onset of a second to another, varying intensity, sometimes intense, usually a short duration.
Their cause is unknown.
The first episode evokes a subarachnoid hemorrhage and examinations to be done to eliminate formally are practicing.The repetition of the same events in the same circumstances helps in the diagnosis.
Nonsteroidal anti-inflammatory drugs are often effective in this type of headache.
This is extremely short pain for a few seconds, usually in the same place of the scalp, which can occur either sporadically or repeatedly in the day and the days.
The cause is unknown.
When accesses are frequent and troublesome, treatment can be offered. It is commonly accepted that these headaches are sensitive to indomethacin.
Other related headache in cluster headache:
Chronic paroxysmal hemicrania:
It resembles the cluster headache with unilateral pain in the orbitotemporal region.
As in cluster headache, there is associated autonomic signs. The pain is intensive, daily attacks.
It affects young adults, but the woman while the AVF is more frequent in men. The crises are shorter than in the AVF, 2-45 minutes against 15 to 180, and the daily frequency of larger attacks in the AVF, 1-40 day against 1-8.
Evolution is chronic and not remitting. She has a remarkable sensitivity to indomethacin.
The short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT) is a rare entity described in 1989.
The model is still the AVF, but the breakthrough pain is short (5 to 240 seconds) and very frequent (5 to 30 per hour).Rather, it affects the man (8/1). It can sometimes bilateralize.
The condition is usually chronic and resistant to treatment.
Other chronic headaches:
Continuous hémicrânie is rare. It is a unilateral headache, chronic. The pain is continuous, very intense, but fluctuating with painful exacerbations. It is often associated with pain in the stabbing. Vegetative manifestations as in cluster headache are common.
Continuous hemicrania are continuous or relapsing and has an absolute sensitivity to indomethacin.
Hypnic Headache Diagnosis:
The hypnic headache is also rare. Patients are awakened every night by a dull pain, often moderate, usually bilateral, rarely with vegetative signs, from 30 minutes to several hours.
It described its sensitivity to lithium and indomethacin.