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Headaches

Headaches can be divided into two major categories, known as primary and secondary headaches. Primary headaches are those that occur for no known cause, and are grouped as either migraine, tension, or cluster headaches. They are said to not be caused by an underlying medical condition, and constitute 90% of all headaches. Secondary headaches are because you have a tumor, bleed, infarction, infection, or other brain injury. Some 12% of all Americans suffer from headaches.

This division is separate entirely from the primary and secondary versions of a brain injury, which include concussions, moderate diffuse brain injury, and severe diffuse injury in the primary category, and secondary containing the things that can continue to happen to you after your brain is bruised, including hypotension, hypoxia, infection, and hematoma.

Vascular headaches can be separated from non-vascular by their throbbing or pounding quality, and sharper feel. Non-vascular headaches are steadier in sensation, and duller. Brain tissue has no sensory nerve endings, so the pain we feel is from the meninges, scalp, blood vessels and muscles.

The headache for which the most people seek treatment is the MIGRAINE.

MIGRAINE = usu unilateral vascular headache with a predictable course and a repetitive cycle, more common in women, grouped: classic, common or complicated. Classic has the aura and is 10-20% of all migraines, usu onset in childhood to young adulthood. Common is most common, 70-80%, onset can be in 40-50's, shares symptom picture with others except for aura. Some 5-10% are complicated, most onset before age 20, neurologic in origin, and the most severe/intense, causing speech problems, CN III palsy, and unsteadiness. THREE QUESTIONS to diagnose migraine: 1) Do your headaches limit activities a day more more in last 3 mo? (5x lasting 4+ hours min to dx migraine) 2) Do you experience nausea w/ the headache? 3) Does light bother you when you have these headaches? Other important S/Sx: pulsating quality, mod to severe pain, decreases routing activity, at least one of these: nausea, vomit, photophobia, blurred vision, injected eyes, phonophobia, no evidence of organic dz, at least 5 attacks, perversions of taste and smell, restless early, irritable, heightened sense of smell, all senses intolerable, constipation early diarrhea late, may be suicidal. FIVE STAGES of migraine: 1) prodrome 24-36 hours prior, sleep disturbance, yawning, fluid retention, food craving, etc 2) aura (only with classic), 3) headache lasting 2-72 hours, common to wake with it, 4) resolution, usu by going to sleep, lysis: vomit, menses or crisis: work, fight, sex, abortive meds 5) postdrome (fatigue), STAGES put another way: vascular headache, nausea, increased splanchnic activity (n/v), increased glandular activity, muscle weakness, drowsiness, depression. COMPLICATED migraines may cause temporary paralysis (hemiplegia), numbness, dizziness, vision changes, may be retinal including temporary partial visual loss, may be status migrainosus (lasts over 72 hours) needing hospitalization, may be othalmoplegic (eye not move right, eyelid droop). TRIGGERS include: TOP THREE hormones, food, stress. Sleep pattern changes, weather changes, musculoskeletal probs, skipped meals. Specific foods that commonly trigger migraines: red wine, aged cheese, MSG, walnuts, rice, cow's milk, egg, chocolate, wheat, orange, benzoic acid, cheese, tomato, tartrazine, pork, and lots lots more. Tyramine from aged high protein foods.

socrates: site, onset, char, radiation, assoc sx, time, exacerbat/relieve, severity, health btw attacks

CN III = Oculomotor nerve, innervates levator palpebrae superioris, superior rectus, medial rectus, inferior rectus, and inferior oblique, which collectively perform most eye movements; Located in superior orbital fissure.

aura = sign of classic migraine that happens just before headache, usu: scintillating sctotoma (central blind spot with ragged edges, 20-40 mins), photopsia (flashing lights, stars, sparks, tactile hallucinations (tongue, lips, hands), olfactory hallucinations), paresthesia (whispers, smells), numbness, unilateral weakness, speech disturbance (aphasia). Aura may occur without headache.

Tension headache = pressing/tightening sensation around head, bandlike, dull, non-pulsating, bilateral, not reduced by routine activity, less likely to have n/v, usu starts before age 20, may have a family history, 9th most common reason for a patient to consult a physician, less than 15/mo is considered episodic, over 15 is chronic, women 2x more likely than men to have them. TX: analgesic and temperamental adjustments, stress management, body work. ETIO: not enough rest, poor posture, anxiety, hunger, stress, depression, fatigue, overexertion, being a perfectionist, overextended, overweight, new job, loss of a job, deadlines, etc.

CLUSTER headache = aka suicide headache, stabbing, unilateral, hot poker in eye, boring pain, eye being pushed out, searing, most in trigeminal divisions I & II, can't sit still, want to bang head against wall while it's happening, debilitating, attack phases last 4-16 weeks of h/a's on same side of head with intervals cluster free, clusters hit several times a day for short time periods, each headache lasts 10 mins to 3 hours, peaks in 10-15 minutes, SX: autonomic hyperactivity on affected side, nose runs, eye tears, ptosis, congestion, only on the one side. Males 6x: females. Onset mean: 30 for men. TRIGGERS: season (spring/fall), may be associated with allergies or business stress, hypothalamus stimulation, wakes person from sleep 1-2 hours after going to bed "alarm clock headache" very severe. Scalp mb tender.

That's it for primary, now on to the secondary causes:

trigeminal neuralgia = aka Tic Doloureux = 2nd and 3rd branch of trigeminal nerve acts up with no warning: stabbing, electrical, paroxysmal, burning, intense pain triggered by various stimuli incl: brushing hair, shaving, yawning, talking, wind, taste, etc. May lead to suicide. Twice as common in females. Most begins after age 40. Lasts a few seconds to less than 2 minutes. Intense pain followed by bothersome sensation.

analgesic rebound headache = medicalese euphemism for junkie's withdrawal headache, pt wants meds, has headache whenever they are off meds, needs serious detox, has headache 6 days/week for 6 months, bilateral, frontal or occipital, non-throbbing, 20% of all chronic are this, onset 2-3 days after ceasing meds, h/a often increased by exertion, SX may include n/v/d, abd cramps, restlessness, anxiety, sleeplessness, diaphoresis, depression, sleep disturbance

dietary related headache: nitrates/nitrites (flushed face), MSG (skin tight on head, gi probs, hungry), nutrasweet, hangover, hypoglycemia

post traumatic h/a = dull, generalized, after injury, need to rule out subluxation

MENINGITIS = viral common, bacterial worst, onset rapid to gradual, ache mb worse in occiput, nuchal rigidity, sore neck, looks very sick, Kernig's sign, fever, collapse, LOC, vomit. Dx via: lumbar puncture: low glucose and bacteria present. Allopathic tx: septicemia -> amputation. More meningitis in NW, H. flu and Meningococcus.

Sinus headache = often fungal, pain over sinuses and in maxillary teeth, fever, yellow discharge, halitosis

dental pain = radiates from affected tooth, tenderness around ear or TMJ, blood shot eyes, tender eyeballs

hypertension headache = dt sudden increase in BP, tinnitus, nose bleed, bruits

intracranial hypertension = usu dt edema, tumor, or pseudo tumor, can be dt swelling from trauma -> increased intercranial pressure. If TUMOR starts mild, lasts secs to hours, mb worse when lying down, progressive, later becomes continuous, deep, steady, worse from abrube chance of position, begin to see signs of cerebral dysfunction, convulsions, papilledema, persistent (projectile) vomiting. Dx: neuro exam, visual acuity, visual fields, CT, chest x-ray, CONSIDER WHEN: aura persists into/after headache, change in previous h/a pattern, epilepsy onset after age 20.

papilledema = optic disc swelling that is caused by increased intracranial pressure. Swelling usu bilateral, can occur over hours to weeks, many possible causes, known to occur in approximately 50% of those with a brain tumor

Cheyne-Stokes breathing = a pattern in which the breathing increases and decreases in depth with regularly recurring periods when the patient does not breathe at all. Cheyne-Stokes breathing is usually associated with severe head trauma that interrupts the breathing center in the brain, causing the irregular breathing pattern. It can also be seen in acute mountain sickness as the body tries to compensate for the lower oxygen levels at higher altitudes. (Dr Thom said that it was associated with heart trouble and I had been taught otherwise, so I looked it up, and Dr Thom is incorrect.)

intracranial hypotension = loss of CSF dt lumbar puncture or dural tear, worse sitting upright, better lying down,

pituitary tumor = compression on sella turcica, pain referred to frontal and temporal regions (bilateral) occ vertex or occiput, first compression probs: optic chiasm, hypothalamus, visual field defects bilateral or uni, diabetes insipidus, pituitary deficiency resulting in multiple endocrine disorders.

temporal arteritis = chronic inflam dz of temporal or occipital area, thickened intima and narrowed lumen, onset late in life, 60 or 70+, often superficial pain, not throbbing, variable intensity, worse brushing hair, pressure when lying down, may have PMR, polymyalgia rhematica, COMPLICATIONS: can cause blindness, ocular SX: ptosis, trAnisent blurring, diplopia, permanent blindness, stroke. Dx: biopsy temporal artery, marked increase in ESR, mb leukocytosis and mild anemia.

polymyalgia rheumatica = PMR = muscle & joint pain, stiff sore upper limbs, worse in AM, Tx: steroids & chemo, insidious onset, gradual development in shoulder girdle, hips, low grade fever, los of appetits, loss of weight, tenderness

subarachnoid hemorrhage = ha dt bleed dt trauma or spontaneous rupture of congenital intracranial aneurism, abrupt alterations in intracranial pressure, SUDDEN ONSET folloed by persistent chronic headache, s/sx looks like meningitis

subdural hematoma = onset is gradual, steady ache with gradual personality change, altered LOC and hemiparesis

temporomandibular joint syndrome usu unilateral pain in tmj or jaw, ear, masseter, temporalis mm., during chew or open wide, popping and clicking, limited mouth opening, can't open 3 fingers wide, bruxism

depressive h/a = vague, generalized, sometimes giddy or undsteady (very nonspecific)

eye pain = dt uncorrected error of refraction, strabismus, glaucoma, uveitis


CLUSTER: TRY EVERYTHING
needs medical excuse, DrT writes for a week then renews if needed
choline for cluster headache
melatonin 10mg/niht x2 weeks
capsaicin .025% in ipsilateral nostril for 7 days
no drugs seem to help

TRIGEMINAL NEURALGIA
DrT has best tx success with single homeopathic rememdies esp Spigelia (L side)
sanguinaria (R)
ars, caust, cham, hep sulph, phos, rhus tox,
cell salts: mag phos, kali phos
b complex
EFAs
meds: carbamazepine, oxcarbazepine, baclofen and lamotrigine
if refractory: Gasserian ganglion percutaneous technique, gamma knife

thyroid??--esp for chronic non-migraine type headaches

ANALGESIC REBOUND
impossible to tx outpt
DrT has no success
thinks they need massive detox
pts will dose up on their drug of choice if it gets bad enough so real issue is addictive response

SOURCES
Dr Thom's CPD and Neurology lectures

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